66 F I S I O T E R A P I E SEPTEMBER 1979 include th e m o re m edially placed p a laeo -sp in o th alam ic fibres. Its co m p licatio n is a very high risk o f d ip lo ­ p ia an d it can n o t be done b ila terally because o f the risk of he arin g loss. It is a p ro ce d u re w ith lim ited a p p lic a tio n an d is done only at a few centres w here p a rtic u larly interested surgeon s p e rfo rm it (N ashold et al. 1969). O P E R A T IO N S O N T H E T H A L A M U S D esp ite m o re th an 20 years o f ac tiv ity in th is field, th e re is little in d ic atio n th a t a single o p e ra tio n , or even a m u ltic en tric o p e ra tio n in this region, w ill give p ain relie f devo id o f co m plications. T h e re is a fairly hig h risk w ith a reasonably low level o f success. It is as yet no m ore th a n ex p erim en tal surgery, best suited to a lim ite d n u m b er o f centres an d n o t u n i­ versally applicab le. It is o f v ery little use in the treatm en t o f th a la m ic p a in and f o r o th e r conditions in w hich it has been tried. B etter m ethods of tr e a t­ m ent a r e available. O P E R A T IO N S O N T H E F R O N T A L L O B E T h ere was a tim e w hen it was th o u g h t th a t a b la tio n o f p a rts o f th e f ro n ta l lobes w o uld solve th e problem o f suffering associated w ith pain. P re fro n ta l leucotom y in te rru p ts the fro n to th a la m ic p ro je c tio n system , and e m otional responses a r e affected m o re th a n intensity o f p a in ex p erience because th e re is no d ivision of fibre tracts d irectly resp onsible fo r th e carryin g of im pulses co ncerned w ith no cicep tion. T o b e effective, these o p e ra tio n s h ave to be ra th e r extensive a n d then ca rry a n u n a cce p tab le risk o f p e rso n a lity disturban ce. W hen they a re o f sm aller fo rm at, they fail in their pu rp o se o f p a in relief. T h e advent o f vario u s psych o­ tro p ic drugs h as m a d e th e u se o f these op e ra tio n s v ery lim ite d indeed. In som e ve ry selected in div iduals w ith p a in , th is type o f o p e ra tio n , p a rtic u la rly th e very lim ite d o p e ra tio n o f cingulotom y, m ay p lay a p art, A p a tie n t w ith an obsessive com pulsive p erso ­ n a lity w ho now has th e b u rden o f being m o rb id ly p re ­ occupied w ith his p lig h t could p e rh a p s be helped. E L E C T R IC A L S T IM U L A T IO N E lectrical stim u latio n can b e effective in co ntro llin g p a in , even if severe an d persistent, alth o u g h ap p re ciab le difficulties an d lim ita tio n s still exist. .Effective pain co n tro l m ethods are transcutaneo us, percutaneous, p e ri­ ph e ra l nerve, dorsal colum n, ventral colum n, thalam ic an d in te rn a l capsu lar stim u latio n . T hese m ethods vary in reg a rd to risk, effectiveness in given p a in problem s d u ra tio n o f benefits and technical difficulties. T he en thu siasm f o r b ra in stim u latio n m ethods has som e­ w h at decreased alm ost as ra p id ly as they have evolved. T h e tech n ical p roblem s o f electrode failu re, electrode m ov em ent an d th e v a ria b ility o f h u m a n an ato m y are m e asu re ab le defects. T h e difficulties w ith p a tie n t selec­ tio n still seem to reign suprem e an d th e success and fa ilu re rates ru n p a ra llel to all oth e r m ethods o f pain treatm en t. T im e is necessary to assess th e long-term results o f treatm en t an d effects on the b rain. I t has a lim ite d a p p lic a tio n in carefu lly selected p atients and this should be don e a t special centres. T h e an sw er to p a in is n o t surgery. It is doubtful w h eth er th e answ er will be electrical stim u latio n be­ cause it is based on the sam e sh aky an atom ico/physio- logical assum ption s as surgery. T h e answ er w ill most likely b e b iochem ical and at th e as yet nebulo us plane of in te ra ctio n betw een chem ical a c tio n an d psych ologi­ cal experience. R eferences A bbe, R . (1889): A c o n trib u tio n to surgery of th e spine. M ed . Rec. N .Y . 35, 149 - 152. M aher, R . M . (1955): R elief o f pain in incurab le cancer. L an cet 1, 18 - 20. M ullan, S., H e k m atp an a h , J., D o bben , G . a n d Beckman, F . (1965): P ercutaneous in tram ed u llary cordotom y u tiliz in g th e u n ip o la r electrolytic lesion. J. N eurosurg. 22, 548 - 553. N ash o ld, B. S., W ilson, W. P. an d Slaughter, D. G. (1969): S tereo tactic m id -b ra in lesions fo r central dys- aesthesia an d p h a n to m pain. J. N eurosurg., 30, 116 - 126. Sjoqvist von O. (1937): E in e neue O p eratio nsm ethode bei T rigem inusneuralgie durch Schneidung des T ractus Spinalis Trigem ini. Z b l. N eurochir. 2, 2 7 4 -2 8 1 . Spiller, W. G. an d M artin, E. (1912): T h e treatm ent of p ersistent pain o f organic origin in th e low er p a rt of the body by division o f th e an tero lateral colum n of th e spinal cord. J. A m . M ed. Ass. 58, 1489- 1490. Sweet, W. H . an d W epsic, J. G. (1974): C ontrolled therm ocoagulation o f th e T rig em inal ganglion and rootlets fo r differential destruction o f pain fibres. P a rt I: Trigem inal neuralgia. J. N eurosurg. 40, 143 - 156. T H E ATTITUDE O F T H E MEDICAL PROFESSION TO CHIROPRACTIC t J. N. D E K L E R K * M .B. Ch.B. (U.C.T.), F .R .C .S . (Edin.) H IS T O R IC A L B A C K G R O U N D T h e p h ilo so p h y u nd erlying c h iro p ra c tic was first p ro p o u n d e d by D a niel D a vid Palm er in the city of * H e ad , D e p t o f U rolo gy, U n iv ersity o f Stellenbosch an d C h airm an , F e d e ra l C ouncil, M edical A sso ciation o f S ou th A frica, t A ddress given to ph y sio th erap ists and stu den ts as p a rt o f C ongress an d 13th N atio n al C ouncil in C ape T ow n, 27th A p ril 1979. D av en p o rt, U.S.A., in 1895. P alm er claim ed th a t the secret o f a ll disease had been revealed to him and it w as caused by displaced v e rte b rae w h ich pressed ag ainst nerves. “By displacem ent an d pressure, they elo ng ate the p athw ay o f th e nerve in a m a n n er sim ilar to th a t by w hich an im pin gem ent u p o n a w ire o f a m usical in stru m en t induces it to becom e ta u t by displacing it. fro m a direct line. T his pressu re upon a nerve creates g rea ter ten sion , increased v ib ra tio n and consequently an increased am o u n t o f heat. H e a t alters tissue; a lte re d tissue m odifies transm issio n o f im pulses; m odified im pulses cause fu n c tio n to b e p e rform ed R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) SEPTEMBER 1979 P H Y S I O T H E R A P Y 67 ab n o rm ally .” T h is “p rin c ip le ” w hich P alm er claim ed to have discovered is still the fram ew o rk o f reference fo r the m o d ern ch iro p ra c tic e philo so ph y. T h is p h ilo so p h y is clearly en u n ciated by A. E. H o m ew ood (1973) w ho states: “T h e fo u n d er o f the science o f ch iro p ra ctice ap p re ciate d the w orking of U n iversal Intelligence (G od ); th e fu n ctio n o f In nate Intelligence (Soul, Spirit or S park o f Life) w ithin each, w hich h e recognised as a m in u te segm ent o f U niversal; and th e fu n dam ental causes o f interferen ce to the p lan n ed expression o f th a t in n a te Intellig ence in the fo rm o f M ental, C hem ical an d /o r M ech an ical stresses, w hich create th e s tru c tu ra l d isto rtio n s th a t in te rfere w ith nerve supp ly and th e re b y result in a lte re d fu n c­ tion to th e p o in t o f dem onstrable cellular change, know n as p a th o lo g y .” In th e course o f tim e there were certain m odifica­ tions in this basic ap p ro a c h but the u nd erlying p h ilo ­ sophy rem ained essentially th e sam e an d could be sum m arised in the five basic p rin cip les laid dow n by the P residen t o f th e N a tio n a l College o f C h iro p ractic jn C hicago, Illin o is, Jo seph Jan se (1975). T hese basic p rin cip les relate to “p u r e ” c h iro p ra c tic e an d differ w idely fro m those o f m o re recent origin. T h ey are: % T h a t a v e rte b ra m ay becom e su blux ated; # T h a t this su b lu x atio n tends to im pin gem ent on stru c­ tures (nerves, bloodvessels an d lym phatics) passing th ro u g h th e in te rv e rteb ral fo ram in a; ® T h a t as a result o f this im pingem ent, functioning of the co rrespon ding segm ent o f the spinal cord an d its co nnecting spin al and a u to n o m ic nerves are in te rferred w ith and co nduction o f n e rv e im pulses is im paired; $ T h a t as a result thereof, th e in n e rv a tio n to certain parts o f th e organ ism is ab n o rm ally a lte re d and th e re fo re such p a rts becom e fu n ctio n ally o r o rg an i­ cally diseased o r predispo sed to disease; % T h a t ad justm en t o f su blux ated v e rte b ra e rem oves the im pin gem ent o f the stru c tu re passing th ro u g h the in terv erteb ral foram ina, thereby restoring to diseased p a rts th e ir n orm al in n e rv a tio n an d re ­ h a b ilitatin g th em fu n ctio n ally and organically . It needs to be p o in ted o u t th a t n o t only is this so- called “ influence” effected fro m v e rte b ral colum n to the in tern al organs, b u t according to th e c h iro p ra cto r it can w o rk in th e reverse d irec tio n also. T h e c h iro ­ p rac to r believes unequivo cally th a t the fu n c tio n o f the vertebral colum n m ay b e reflexly affected by a p a th o ­ lo g ic a lly diseased in te rn a l organ. I q u o te: . . m o re­ over it is possible th a t in te rn a l o rg an ic affections alter oy reflex pathw ays the fu nctio ning o f th e v e rte b ral co lum n as an organ o f s u p p o rt and m ovem ent; the rece p to r organs send back a n e x citatio n to th e ir p o in t of orig in ; th e in tern al o r external organs, m aking use of the spinal p athw ay (cells o f D ogeil) (sic!) w hich m ay be considered on the one hand as a revealing index of m o rb id in te rn a l processes an d o n the o th e r han d as an aetiological fa c to r in num erous phy sio -patho log ical affections. T h e p ain an d d iso rd er being th e only signs of a vicious circle w hich only an a ttem p ted physical exam ination will be able to break.” (M y italics) I t is clear th a t the concept o f v e rte b ral su blux ation is central to th e “p u r e ” c h iro p ra c tic philo sophy. A m ongst m o d ern c h iro p ra cto rs this concep t has led to co nsid erab le confusion. H aldem an (1975) states: “T he d e term in atio n o f th e clinical significance o f sp in al su b ­ luxation has been clouded b y the large n u m b er o f w idely varyin g and in m an y cases, d ia m etrically o p ­ posed op in io n s on this subject w hich has often been dog m atically ad h ered to w ith o u t a d eq u a te investiga­ tion. T h e exact clinical significance rem ain s difficult to d eterm in e because o f th e g rea t diversity in its aetiology, th e com plex n a tu re o f the sublux ation and the com ­ p a ra tiv e lack o f research .” In N o vem b er 1972 a p a p e r on “T h e radiolo gical m a n ife sta tio n o f spinal su b lu x atio n s” was presented at the H o u sto n C onference o f C h iro p racto rs. T his p roved to b e no m o re than the well recognised signs of degenerative spinal disease (spondylosis) fam iliar to every p ractising radiologist, o f w hich you all a re well aw are, present in th e great m a jo rity o f spin al ra d io ­ grap h s done o n eld erly p a tien ts who do n o t necessarily have sym pto m s referab le to th e spine. T h is a p p a re n t co nfu sio n has led to nu m ero u s attem pts to redefine ch iro p ra ctic. Joseph Janse in his p a p e r “T he h isto ry of the developm ent o f the c h iro p ra ctice con­ ce p t” (1975) gives f o u r different definitions an d in no single one o f these definitions does h e include the concept o f sub lux ation. F r o m this p a p e r it seems that the basis o f m o d ern “p u re ” ch iro p ra ctice is in fact m an ip u la tiv e th e ra p y and n o t the co rrectio n o f verte­ b ral sublu x atio n. T h is is how ever n o t th e end o f the p ro b le m as fa r as th e m edical p rofession is concerned. W e m ust clearly u n d ersta n d th a t th e m od ern c h iro ­ p ra c to r believes th a t he h a d been train e d fo r an d is entitled to functio n as a prim ary physician a n d is in no way p re p a re d to lim it his practice to the m anagem ent o f m uscu lo-skeletal infirm ities by m eans o f m a n ip u la ­ tive th erapy. H e believes th a t he has th e rig h t to p rac tise m ed icin e o n the sam e basis as the o rthod ox fam ily p rac titio n er, a quite different concept fro m th at w hich is ad h ered to by th e “p u re ” ’ ch iro p ra cto r. T o illu strate th e degree to w hich the ch iro p ra c to r claim s his rig h t as a p rim a ry h e alth p ro v id er, it w ould be su ita b le p e rh a p s at this stage to ex tra ct a section of a re p o rt by th e R o y al C om m ission on Social Security in N ew Z eala n d (1972), in w hich D r. A. W . S. T h o m p so n fro m the New Z ealan d D e p artm en t of H e a lth cross-exam ined M r. W . L. R h eed er o f the New Z eala n d C h iro p ra c tic A ssociatio n: D r. T h o m p so n : “I f there w as a c h iro p ra c tic benefit (m edical schem e) w o uld ch iro p ra c to rs tre a t children w ith w h ooping cough u n d e r this schem e?” M r. R h eed er: “I can only an sw er th a t this is a possi­ b ility .” D r. T h o m p so n : “T a k e a p a tie n t obv iously suffering fro m diabetes. W ould y o u o r a re p u ta b le c h iro ­ p ra c to r tre a t such a p a tie n t? ” M r. R heed er: “Y es”. D r. T h o m p so n : “I u n d ersta n d you to say th a t d iabetics you w ould tr e a t? ” M r. R h eed er: “Y es”. D r. T h o m p so n : “By spinal m a n ip u la tio n ? ” M r. R h eed er: “Y es”. D r. T h o m p so n : “W h a t a b o u t h ig h b lo o d p re ssu re ? ” M r. R h eed er: “I t depends on its o rig in , b u t perhaps y o u r h o n o u r, could I ask f o r y o u r guidance on this p a rtic u la r p oin t. W e have discussed several specific d isorders th a t D r. T h o m p so n is asking me. A re we going th ro u g h fro m A - Z ? ” T h e C h airm an : “I d o n ’t kno w w h at you are, but it seems the d o c to r was getting into an a re a w hich was so different fro m th e im pression you gave from yo u r d escrip tio n w hat y o u r activities w ere.” It is a b u n d a n tly clear, if th e re is to b e an y questio n of a ch irop ractic p rim ary health system , such a system w o uld fall fa r short o f th e accepted standard s of m edical ca re in South A fric a and w ould only be u tilised to pro v id e an easy access to m edical practice fo r peop le who are in cap ab le o f o r unw illing to u n d e r­ go a recognised m edical train in g program m e. This claim to th e right to practise as a physician capable o f p ractisin g a t p rim a ry h e alth ca re level is clearly o u tlin ed b y E dw ard J. M cG innes, (1977) C h a ir­ m an o f th e A m erican C h iro p ra c to rs A ssociations, who am ongst o th e r things states: “W e m ust be skilled in R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 68 differential diagnosis and be alert to th e necessity of referral to specialties w hen in d icated .” S im ilarly the New Z ealand C h iro p racto rs A ssociation (1975) states: ‘'A c h iro p ra c to r learns to becom e a co m petent diag­ nostician so th a t w here surgery o r o th e r health treat­ m ent is indicated, h e m ay im m ediately refer such p atien ts.” F ro m the forego in g it ap p ears q u ite obvious th a t this a p p ro ach no w places th e c h iro p ra c to r in a dilem m a: m ust h e in o rd e r to q u a lify as a p rim a ry poin t o f en try into the h e alth care system discard his “p u r e ’ ch iro p ra ctic p rincip les, reno u nce his claim as a m em ber of th e “largest drugless healing p rofession” (Brom ley, 1975) and re fe r his p a tien ts to the m edically qualified p ra c titio n e r w ho is allow ed to p rescrib e these drugs, o r m ust he re tu rn to the preserv atio n o f chiro- practice in its “p u r e ” form . T he claim o f th e m odern ch iro p ra c to r th a t he is sufficiently qualified to practise as a p rim a ry health care physician is w hat concerns me m ost. T here is ab u n d a n t evidence to show th a t these ch iro p ra cto rs regard th e ir scope as being m uch w id er th a n com m only supposed. T h ey tra in and p ractise as a p rim a ry p h y si­ cian not as a m a n ip u la tiv e th e ra p ist (The C h iro p ractic B oard New Z ealand, 1978). L et us now exam ine the basis fo r these claim s: TH E CHIROPRACTIC T R A IN IN G PR O G R A M M E T h e c u rricu la o f ch iro p ra ctic colleges are m ost re­ vealing. I t is safe to say th a t w ith th e exception of surgical procedures, there is not a single elem ent o f medical practice fo r w hich the chiropractic colleges do not claim to provide training. Paediatrics, internal m edicine, psychiatry and any m edical discipline you wish to nam e, are taught. One can tak e any Journal o f C hiropractic pub lish ed m on thly by th e A m erican C hiropractic A ssociation and you will find articles on p a ed iatric infections and viral diseases, digestive p r o b ­ lems, re sp ira to ry problem s, g en ito -u rin ary problem s, “the m ega-vitam in a p p ro ach to sch izo p h ren ia ,” (sic!!) diabetes m ellitus, atherosclerosis and the m anagem ent o f an g in a pectoris. All o f these disciplines are taught despite the fact th a t the A ccrediting C om m ission o f the D e p artm en t o f H e alth , E d u ca tio n and W elfare o f the U n ited States has rep o rte d th at c h iro p ra c tic th e o ry and practices are n o t based upo n the body of basic know ­ ledge related to h ealth, disease and h e alth care that has been w idely accepted by the scientific com m unity (U.S. D e p artm en t o f H e alth , 1968). In b o th ^ th e U n ited States o f A m erica and C an ad a the train in g w hich is prov id ed is q u ite ap p aren tly n o t directed solely tow ards the m a n ip u la tiv e tre a tm e n t o f m usculo-skeletal dis­ orders. M ajo r ch irop ractic schools provid e a 4-year course o f in s tru ctio n in two b ro ad categories, viz basic science an d c h iro p ra c tic p rincip les. T h e basic sciences include an atom y, chem istry, physiology, p a th o ­ logy and m icrob iology , and c h iro p ra ctice p rin cip les in ­ clude c h iro p ra c tic tech n iq u e and d ifferential diagnosis. A ccording to a re p o rt to the M in iste r o f H e a lth of N ew Z ealan d (C onsum er R eview 9, 1976), no evidence could be ad duced to show th a t the teaching o f scientific subjects was conducted by qualified personnel. TH E V A L ID IT Y OF CHIROPRACTIC T h e c h iro p ra cto rs hav e strenuou sly advocated that they m ust be regard ed as a valid healing a rt distinct fro m oth e r m edical services. T o quo te a few sources: “It is the reason w hy th a t th e science of chiropractic offers th a t differentiates th e practice fro m th a t o f the m edical profession.” T h e A m erican C h iro p ractic A sso­ ciation states: “ (it) strongly supports chirop ractic as a sep ara te and distinct h ealing a rt.” T h e In te rn a tio n a l C h iro p ra c tic A ssociation states its co ncern w ith “the preserv atio n s o f ch iro p ra ctic as a se p a ra te an d distinct health care service.” T h e N ew Z ealan d C h iro p ractic A ssociation states: “T h e ch iro p ra ctic p ro fessio n has developed as a separate and d istin ct p ro fe ssio n in the healing arts due to its ad h eren ce to p rin cip les which have been rejected by organ ised m edicine. In this context we should n o te the w ords o f th e A m erican C h iro p ra c tic A sso cia tio n ’s Presiden t, S tep hen E. Ow ens (1974): “F in a lly , we a re healers in th e m idst of this ex trao rd in ary therap eutic drug c u ltu re explosion w ith its iatro g en ic nigh tm ares, su rgical prom iscuity, h o sp ita l h o rro rs and m erchants o f m e d icin e crying that h e alth can b e purch ased . . . ” T hus w h ilst the “p u re ” c h iro p ra c to r denigrates m o d ern m edical p ra c tic e at every o p p o rtu n ity , th e m o d ern c h iro p ra c to r today finds him self increasingly faced w ith a s itu a tio n w h ere of necessity h e w ill h ave to a lte r his inflexib ility with regard to the accepted stan dard s o f W estern m ed icin e if h e wishes to be accepted as a p rim ary health care pro v id er. This latte r concept o f th e scope o f ch irop ractic is w h at concerns th e b o n a fide m edical p ra c titio n e r the m ost. W hereas it m ig h t be argued th a t th e activities of ch iro p ra cto rs involved in p rim a ry h e alth ca re can be carefu lly lim ited b y legislation, this is n o t the case. T h e C om m ission on C h iro p ra c tic in S ou th A frica (1962) states: “T h e p rin cip le o f c h iro p ra c tic does not lend itself to restric tio n and th e re fo re it is n o t possible to define the scope o f his p ra c tic e o r list diso rders to w hich it can b e restricted. In o th e r w o rd s, co n ditional reco g n itio n o f ch iro p ra ctic is n o t p ra c tic a b le .” T his has been b o rn e o u t clearly b y th e fa ilu re o f N o rth A m erican legislators to re stric t th e scope o f ch iro ­ practic. A lth ough u n acceptable by leg itim ate m edical stan­ dards, do th e c h iro p ra cto rs then p ro v id e a specialised service beneficial to p a tien ts an d th e glob al health service? In A u stra lia the A u stralia n C om m ittee of E n q u iry into C h iro p ractic e described th e reactio n s of p atien ts u n d e r ch iro p ra ctic care thus: “ . . . alm ost u n ifo rm ly th e re was an extrem ely hig h level of satisfa ctio n expressed w ith th e care received and the im prov em ent experienced as a result of treatm en t.” T h is study indicated th a t ap p ro x im ate ly 50% o f patients seeking c h iro p ra c tic care had previo usly consulted (other) m edical p ractitioners o r ch irop ractors. I f this is indeed so, it behoves us to investigate by what m eans this p a tie n t satisfa ctio n has been attain ed . T here a re v ario u s possibilities to consid er: i 9 Is it due to m an ip u la tiv e d ex terity and te c h n iq u e ? ' A lth o ugh it is po ssib le th a t som e o f the benefit w hich is derived fro m c h iro p ra c tic care m ay be due to the actual process o f m a n ip u la tio n , how ever it b e described, th e re is no objective evidence for o r ag ainst this hyp othesis, e ith e r fro m ch iro p ractic o r o th e r sources. So it is to b e no ted th a t the N IN D S W o rk sh op on the R esearch Aspects o f Spinal M anipulative T h erap y (G oldstein, 1975) and th e staff review and analysis o f av ailab le data, clearly in d ic ate th a t specific conclusions could not be derived fro m scientific lite ra tu re f o r o r against the p rac tice o f spinal m a n ip u la tiv e th e ra p y o r the path o p h y sio lo g ic fo u n d a tio n fro m w hich it is derived. 9 Is it possibly a placebo effect? In o th e r words, a m ethod o f tre a tm e n t given m ore to please than to benefit th e p atien t, in m an y respects sim ilar to ths practice o f “laying on o f han d s.” 9 Is th e ch iro p ra c to r m ore versed in a p ro p e r doctor/ p a tie n t relatio n sh ip ? A recent stud y concluded by th e U n iv ersity o f U ta h College o f M ed icine (Kane, et al., 1974) show ed th a t th e re was no essential SEPTEMBER 1979F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) difference in th e o utcom e o f th e ra p y fo r low b a ck ­ ache w h eth er given by a m edical p ra c titio n e r o r a ch iro p ra c to r b u t th a t th e p a tien t o f th e c h iro p ra cto r was m ore satisfied w ith the degrete to w hich he was m ade to feel welcome. T h e au thors o f this study stressed th e im p lication s o f these reactions. “On th e basis o f o u r study and others, it ap pears the ch iro p ra c to r m ay b e m o re attu ned to th e total needs o f th e p a tie n t th a n his m edical co u n terp a rt. T he ch iro p ra c to r does n o t seem h u rrie d , he uses language patients can u n d erstan d , he gives them sym pathy an d he is p a tie n t w ith them , he does n o t tak e a su p erio r a ttitu d e tow ards them . In sum m ary, it is an in tim a te relatio n sh ip ra th e r th a n a su p e rio ro rd in a te / s u b o rd in a te re la tio n sh ip .” T h e c h iro p ra c to r has de­ veloped th e a rt of self-projection w hich he astutely ap plies at p a tie n t as well as all o th e r levels. @ A re those cases w h ich ap p e a r to benefit n o t m erely cases o f spon taneo u s rem issio n? T h e m od ern c h iro ­ p ra c to r considers him self com petent to treat a wide range o f illnesses b u t the m a jo rity o f patients ap p ear to co nsu lt h im m ore fo r m usculo-skeletal diso rders th a n o th e r illnesses. It is recognised th at the m ajo rity o f m usculo-skeletal disorders do show a strong tendency tow ards self-lim itation, w h eth er the p a tie n t receives treatm en t o r not. In m any cases th ere are periods, often long, o f spontaneou s re­ m ission. F o r exam ple, you all know th a t the sym p­ tom s o f lu m b a r degeneration are classically episodic. T h e efficacy o f an y fo rm o f treatm en t o f m uscu lo­ skeletal disorders is th erefo re noto rio u sly difficult to assess and it rem ains a m a tter o f speculation w h ether the clinical im provem ent claim ed fo r ch irop ractic care in a given case is due to the coincidence o f spontaneou s rem ission. In all p r o ­ b a b ility th e tr u th lies som ew here in the m idd le o f all these facto rs. W h atev er the reason, th e fact is still qu ite clear — no th ing w hich th e c h iro p ra cto r does can n o t b e equally well p e rform ed by the m edical p ra c titio n e r an d /o r th e physio therapist. T HE RISK OF CHIROPRACTIC It m ay be argued th a t provid ed th e p atien t is satis­ fied and is relieved o f his sym ptom s, it doesn’t really m a tter w h eth er h e goes to a m edical p ra c titio n e r o r to a ch iro p ra cto r. T h is m ay be a reason able assum ption p rovided th a t th e re is no risk attached to c h iro p ra ctic treatm ent, and his m ethods o f treatm ent are n o t noxious )as f a r as th e p atient is concerned. T h e principle risk of ch iro p ra ctic lies in the fallacious philo so ph y th a t all disease is am en ab le to treatm en t by m anipulative th erapy. T hus th e treatm en t o f infectious diseases (such as w h ooping cough), the treatm ent o f severe system ic diseases such as d iab etes m ellitus, essential hy p erten ­ sion and such like co nditions, by m eans o f c h iro p ra ctic m anipulation, serves to delay th e p ro p e r m anagem ent of serious life-threatening conditions. In this respect th e re­ fo re th e re is a very real risk attached to chiropractic treatm ent. Spin al m an ip u la tio n is no su b stitu te for ganglion blockers in the treatm en t o f hypertension, en d o crin e th e ra p y in dissem inated cancer o f th e p r o ­ state, in su lin in th e treatm en t o f diabetes, im m u nisation in th e prevention o f w hooping cough, o r antibiotics in the treatm en t o f th e com plications o f w hooping cough. T h is risk is n ow here m ore ap p aren t th a n in the case o f sick children. T h is was clearly recognized by a rep o rt issued in 1972 by the M o n trea l C hildren’s H ospital. “By calling him self “d o c to r” , by taking X- rays, by p retending to b e qualified, th e ch iro p ractor creates a false im age as to his a b ility to deal with p a ed iatric problem s. T h is leads directly to th e delay in p ro p e r diagnosis being m ade and the co rrect therapy SEPTEMBER 1979 being started which m ight affect the child fo r th e rest o f his life.” S im ilarly in 1975 th e U n ite d States C on­ sum ers U n io n (C onsum er R ep o rts, 1975) recom m ended the follow ing: . . th e C o nsum er U n io n believes that ch iro p ra ctic is a significant h a zard to m any patients. A b ove all, we w ould urge th a t the ch irop ractors be p ro h ib ite d fro m treatin g children. C h ild ren do not have th e freedo m to reject unscientific th e ra p y th a t th e ir pa re n ts m ay m istakenly tu rn to in a crisis” . F o r “ch ildren” you can also substitute th e unsophisticated p a tie n t in o u r com m unity , the old and w eary g e ria tric p a tie n t who has lost his ab ility to clearly distinguish fact fro m fiction, and the em otionally unstable who read ily fall p re y to th e sales p a tte r an d d e n ig ratory activities o f th e ch iro p racto r. N o w here is this better illustrated th an in their use of radiology! M an v o f us who have been in p ractice in this co u n try are ap p alled by th e u n b rid led use o f ra d io ­ logical eq u ip m en t b y ch iro p ra cto rs an d the highly q u e stio n ab le diag nostic m ethods w hich are used to describe fan c ied spinal displacem ents an d subluxations. I q u o te fro m a r e p o rt fro m th e New Z ealand C h iro ­ p rac tic B oard (Howe, 1974): “X -ray p h o tograph y is of special im po rtance because o f its ab ility to depict for th e ch iro p ra cto r th e fu n c tio n a l abnorm alities (my italics) o f th e spinal colum n in addition to the various pathological alte ra tio n s w hich m ay o ccu r in the osseous o r so ft tissues o f th e body . . . A lteratio n s o f spinal alig nm en t in fu n ctio n are frequently well depicted by th e use o f b o th static and stress rad io g ra p h y .” T his reliance on interpretations which at best are o p en to serious diagn ostic deficiencies speaks fo r itself. M o re recently these people have com m enced doing extensive path o lo g ical la b o ra to ry studies. T h is is som e­ thing w hich o u r M edical and D en tal C ouncil does not allow a p ra c titio n e r to do unless adequate specialised tra in in g has been und ergone. T h e c h iro p ra cto r draws bloo d w ith im pu nity, p e rfo rm s these la b o ra to ry tests and creates th e sp u rio u s p u b lic im age o f an a b ility to in te rp re t and tre a t b iochem ical disturbances due to disease. POLITICAL ACTIVITY ' In the U.S.A. (and in the R .S.A .) these people have an extensive p o litical lobby. T h e ir freedom o f p ro ­ fessional ac tiv ity is the result o f this extensive political action. A c h iro p ra c to r is a p o litic al realist an d chro- practic organisations in this co u n try are m aking deter­ mined efforts to achieve the goal o f recognition as an in depen d ent p rim a ry m edical care profession so as to legitim ise paym ent by the m edical aid schemes. H ow th is p a rtic u la r action has been m ou nted in the U.S.A. has been very succinctly expressed by one W . D. H a rp e r, (19741 at th a t tim e P resid en t o f the Texas C h iro p ra c tic College, who stated: . . w ith th e in ­ sidious trend tow ard s socialised m edicine in this co u ntry (U.S.A.) even thou gh it has o r is failing in others, we m ust p rep a re ourselves to be p a rt o f a team o f health pro vid ers . . . and b e p rim ary care physicians o f th e fu tu re if we are going to get a piece o f action.” (my italics) T h e ro le o f politics in the fu n ctio ning of the ch iro­ p ractic lobby is well described in a special consum er re p o rt p ub lish ed by th e C onsum ers U n io n o f the U.S.A. Inc. as recen tly as O c to b er 1975: “ . . . C h iro ­ p rac to rs to d ay en joy a w ider rang e in th e ir scope of practice th a n an y o th e r h e alth p rac titio n er, except a physician. By com parison, oth e r independent health care p ro v id ers m ust practise w ith in f a r stricter limits. A d entist does n o t tre a t stom ach ulcers, a psychologist d o esn’t o rd e r m e d icatio n fo r h e a rt conditions, an o p to ­ m etrist does n o t tre a t epilepsy, b u t ch iro p ra cto rs may 69P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 70 often do all th re e an d they a re p erm itted to offer tr e a t­ m e n t in specialities rang in g fro m p a ed iatrics to psy­ ch ia try w ith o u t having th e scientific tra in in g in o ne o f them . C h iro p ra c tic has w on th a t freed o m (w ith o ut en ­ gaging in research o r d em o n stratin g professional capacity in these fields) b y o ne m e th o d alo n e — p o liti­ cal action. F o r years, grass ro o ts p o litics has been the life b loo d o f ch irop ractic. By m assing th e s u p p o rt o f ch irop ractic patien ts, the profession has often achieved an effective p o litic al voice in leg islation affecting its ch iro p ra ctic services an d th a t voice has been its p ro ­ tection ag ainst science. O p ponents o f ch iro p ra cto rs com e to legislative hearings w ith in fo rm atio n , w ith scientific studies an d w ith the official en dorsem en t o f n a tio n a l o rgan isatio ns. C h iro p ractic comes arm e d w ith v otes.” R ead ers m ay well b e aw are th a t a som ew hat sim ilar situ atio n occu rred in S outh A frica w ith the C om m is­ sion o f E n q u iry into th e P ractice o f C h iro p ractic in ­ stitu ted by th e G o v ern m e n t in O ctober 1962. A t present every po ssible av enue is continually ex plored to p ro ­ m o te th e ir interests a t social an d p o litic al level. H e alth farm s a re read ily av ailab le to p o litic ian s an d th e ir wives, every o p p o rtu n ity to speak to p a rlia m en ta ry g roups is tak en — now an a tte m p t is even being m ade u n d e r th e guise o f involvem ent w ith th e H e a lth Y e ar to address schools an d social clubs! TO SU M M ARISE M o dern c h iro p ra c tic q u ite ap p aren tly encourages persons w ith lim ite d qualifications to practise m edicine u n d e r a n o th e r nam e. T h e tra in in g p ro g ram m e o f the m od ern c h iro p ra c to r is g eared to the ro le o f a p rim ary p hysician, an d n o t as a m a n ip u la tiv e therap ist. T h e r e stric tio n o f th e ch iro p ra c to r to m a n ip u la tiv e th e ra p y a lo n e is n o t p rac ticab le as long as the ch iro p ra c to r is allow ed to p ro jec t him self to the p u b lic at larg e as a p rim ary p hysician. T h e re is q u ite a p p aren tly no dep th of tra in in g in d iagnostic m ethods, an d th e essen­ tial skill o f th e phy sician is lacking in ev ery aspect o f m edical th e ra p y w ith th e possible exception o f the m anagem ent o f m in o r m usculo-skeletal ailm ents. T o d ay m o d ern c h iro p ra c tic tra in in g differs m arked ly fro m th a t given in m edical schools, by v irtu e o f its p o o r q u a lity an d th e s in g u la r em phasis w hich is placed u p o n c h iro ­p ra c tic — spinal adjustm ent. A lth ough m a n y p atients sw ear by ch iro p ra cto rs and state th a t they receive g rea t benefits from , th e ir tre a t­ m ent, the op posite is indeed also true. T he cases of serious, life-th reate n in g disease w h ich a re allow ed to progress u n d e r th is ty pe ofj m anag em en t are com m on knowledge am ongst th e m edical profession. A v ailable scientific evidence suggests th a t th e benefits ap p aren tly derived, if indeed tru e, are largely d ue to th e tra n s­ ference o f confidence fro m ch iro p ra c to r to p a tie n t; the sh arin g o f fa ith in m a n ip u la tio n as a fo rm o f therapy ; the placebo effect o f th e laying on o f hands an d the fa c t th a t th e m in o r m usculo-skeletal d isorders w hich fa , into th e p ro v in ce of ch iro p ra ctic a re them selves self-lim iting o r subject to spontaneou s rem ission. M o d ern chirop ractic is n o t a healing art, separate and distinct fro m legitim ate m edical an d param edical disciplines. I t is n o t based on soun d scientific and educational facto rs an d there is little evidence to suggest th a t it can m ake a co ntrib ution to th e h e alth services of South A frica a n d in p artic u lar at p rim ary h e alth care level. T here is noth in g th a t th e ch iro p ra cto r can provide th a t can n o t be m o re th an ad equately provid ed fo r by th e legitim ate m edical and param edical services. The p reservation o f this form o f thinly disguised quackery is a serious reflection on th e stan d a rd o f m edical care w hich we profess to u ph o ld in S outh A frica. Bibliography Brom ley, W. H . (1975): W h a t’s right w ith th e A.C.A.! T he A .C .A Journal o f Chiropractic, 12, 11 (June). C onsum er R eports, C hiropracto rs: H ealers o r Quacks? C onsum ers U n io n U.S.A. (Inc.) 1975. C onsum er R eview 9. C h iro p ractic , F a c t o r Fictio n? C onsum ers In stitu te o f N ew Z ealand, 1976. G o ldstein, M . (1975): T h e research status o f spinal m anip ulative therapy . T h e introd u ction , sum m ary and analysis. U.S.A. D ept, o f H e alth , E ducation and W elfare P u b l no. N IH 76 - 998. H aldem an, S. (1975): T h e patho-p hysiolog y o f the spinal subluxation. Journal o f C .C .A ., 19, 5 (September), j H a n n a n , T h e H o n o u ra b le J. R ., N ew Z ealand P arlia­ m en tary D ebates, Oct. 1960 325, 3362. H a rp e r, W. D . (1974): A n ything can cause anything. S eabrook Texas. H o m ew ood, A . E. (1973): T h e N eurodynam ics of vertebral subluxation. C hiropractic P ublishers, Canada (page 80). H ow e, J. (1974): R ontgenology in ch iropractic. State of th e art, 1974. A .C .A . Journal o f C hiropractic, 8, 526 (M ay). H ow e, J. W . (1976): A co ntem p o rary perspective on ch irop ractic an d th e concept of subluxation. The A .C .A . Journal o f chiropractic, X /S -165. Janse, J. (1975): H isto ry of th e D evelopm ent o f Chiro­ p ractic C oncepts. C h iro p ractic T erm inology. U.S. D e p artm en t of H ealth , E ducation and W elfare, Publi­ cation no. N IH 76 - 998. K ane, R. L., Leym aster, C., O hlson, D ., W olley, F . R., F isch er, F . D. (1974): M anip ulating th e patient. Lan cet, 1. 1333. M cG innes, E . J. (1977): T he nu m b er one priority. The A .C .A . Jo urnal o f Chiropractic. 14, 13 (February). M em oire presented on b e h alf of th e St. Justine’s H ospi­ tal an d th e M o n trea l C h ild ren ’s H o sp ita l to th e P ar­ liam entary Com m ission on Bill 269 (C hirop.) February 1972. Owens, S. E. (1974): R eferral. W ould you go to y o u ! T he A .C .A . Journal o f Chiropractic, 11, 10 (April). R e p o rt o f th e R oyal C om m ission of E n q u iry into Social S ecurity in N ew Z ealand, tran scrip t o f pro­ ceedings, T h u rsd ay 15-10-70. T h e A u stralian Com m ission o f E n q u iry into C hiro­ practic. T he C h iro practic B oard N ew Z ealan d 1978, T h e Logan College o f C hiropractics 1977/8 catalogue, The N a tio n al College o f C hiropractic Bulletin o f In form a­ tion 1977/8. T he N ew Z ealand C hiro practo rs A ssociation (Inc.) — T h e ch iro p ra cto r in N ew Z ealand, 1975. U.S. D e p artm en t o f H ealth, E d u catio n and W elfare, Indep endent p ractitioners study. W ashington, DC: G o vernm ent P rin tin g Offices, 1968. SEPTEMBER 1979F I S I O T E R A P I E R E SO L U T IO N R E G A R D IN G PUBLICITY “T H A T th e Incom ing N .E .C . in th e in te re st o f the p u b lic im age o f p h y sio th erap y re m in d m em bers o f its policy i.e. th a t P h y sio th erap ists w ho a re interview ed by the p u b lic m edia etc m ust req u e st th e perm ission P A S S E D A T 13 T H C O U N C IL M E E T IN G o f N .E .C . o r in retro sp ect o f an interview in fo rm the N a tio n a l E xecutive C om m ittee o f th e proceedings and th a t th e N .E .C . ex ert carefu l d iscretio n w hen such ap p licatio n s are received.” R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )