Rarely is the birth of a new idea or a new organization the consequence of a singular event. However, the genesis of a new profession, chiropractic, is attributed to the date of 18 September 1895 and the place, Davenport, Iowa. Daniel David Palmer placed his hands upon an irregular protrusion of the spine of Harvey Lillard and with a forceful thrust reduced the irregularity. As a result, Mr. Lillard claimed to "hear the wagons on the street," something he could not do prior to receiving the treatment (Palmer, 1910).
    At the turn of the 19th century in rural America, health care was a craft more than an art. The integration of science into treatment methods and the training process was severely lacking as evidenced by the condemnation of medical colleges in the famed Flexner Report (Flexner, 1910). The consolidation of "cultural authority" (Starr, 1982) by the allopathic physicians had not yet been achieved and there were numerous competing practitioners such as magnetic healers, herbal healers, hydro healers, bone setters, and homeopaths. The growth of health care alternatives paralleled revivalism in religious practices and was thought to provide the physiological counterpart to the theological perfectionism of the time (Fuller, 1989). This crucible of confusion, filled with vitalism and magnetism, leeches and lances and tincture and plaster, provided a seed bed for creative thinking and new ideas. D.D. Palmer and chiropractic were, to a certain degree, a product of their environment.
    In early 20th-century America, allopathic providers obtained greater "cultural authority" and the respect of those who influenced decisionmaking. Opposition to unorthodox practitioners increased. The allopathic physician charged the doctor of chiropractic with practicing medicine without a license. The doctor of chiropractic retorted that practicing chiropractic and practicing medicine were different. To emphasize this difference, the chiropractic community developed a different lexicon and rationale for its approach (Keating, 1989). Medicine's search for a disease process, assigning appropriate labels, and providing the remedy of the day were different from chiropractic's search for an interference in the nervous system that was stated to ultimately, if not immediately, lead to dysfunction and disease. The doctor of chiropractic rejected the use of medicines and drugs and never incorporated the practice of surgery. Chiropractic was conceived as a more natural approach to healing, drawing upon the body's own recuperative powers.
    Although adversity characterized much of organized medicine's relationship with chiropractic, this polarity was more frequently related to economic, political, and legal considerations than to clinical ones. In fact, D.D. Palmer credits a medical physician, Jim Atkinson, with teaching him about the use of bone setting in other cultures (Palmer, 1910, p. 789). G.H. Patchin, MD, has been credited with helping Palmer edit his book, The Chiropractic Adjuster, and one-third of the first graduating class of chiropractors were medical physicians (Palmer, 1910; Gibbons, 1981).
    Following the Flexner Report (1910), medical education consolidated and strengthened its position in society and both medical education and research have received external financial support through grants from the Federal government and private foundations. Federal funds

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initially supported medical care for veterans and, eventually, for the elderly and disabled. By contrast, chiropractic education remained a tuition-driven, inadequately financed enterprise that received no external support for research. In an attempt to eliminate chiropractic, organized medicine promoted licensing regulations, believing that the inferior education of chiropractic schools would prevent their graduates from passing State Board Licensing Exams (Gevitz, 1988; Wardwell, 1992). This is discussed in more detail in Chapter V. The introduction of Basic Science Boards by the medical profession in 1925 created an additional obstacle to the graduate doctor of chiropractic due to the lack of basic science training in the chiropractic curriculum.
    In response, chiropractic schools upgraded their educational process by expanding the curriculum and employing Ph.D.-level instructors to teach the basic sciences. As a result, chiropractors started to pass the Basic Science Boards. Further efforts to improve the quality of the educational process eventually led to the creation of chiropractic's own national accreditation agency, the Council on Chiropractic Education (CCE), which achieved Federal recognition from the Department of Education in 1974. This agency implemented educational standards for the curriculum and the admission processes. Those schools failing to meet the CCE standards closed their doors. By 1995, all chiropractic colleges achieved accreditation by the CCE. Much like the Flexner Report's impact on medical colleges, the CCE elevated the educational standards of many chiropractic schools.
    Until fairly recently, chiropractic had been attacked by allopathic medicine as an unscientific cult with no research to support its claims of efficacy (Keating, 1993; Wardwell, 1992) (see Chapter VII). Research was neglected in the early years of the profession. Without funding for research and facilities in the tuition-driven, for-profit educational institutions, the limited resources of the early colleges were focused on teaching skills needed for success in practice rather than on developing the knowledge base of the profession. Gradually, pockets of hope emerged: Watkins, Weiant, Higley, Illi, and Janse, among others, sought answers for unexplained treatment outcomes and recognized that a research base could be used to refute the claims of adversaries. The evolutionary development of the Foundation for Chiropractic Education and Research (FCER) has helped to foster a research mentality (see Chapter IX). Beyond sponsoring research studies, FCER embarked in 1977 on a program to support the training and development of the chiropractic researcher. There is now a growing cadre of critical thinkers within the profession and an expanding number of research-oriented individuals outside the profession who are studying chiropractic. By 1996, Federal research grants had been awarded to four chiropractic colleges.
    In recent years there has also been much greater collaboration between chiropractors and the greater scientific and clinical communities in training, research, and practice (Mootz, 1995). Multidisciplinary practice is more common as are editorial and technical collaborations, joint research initiatives, and medical physician support of chiropractors in litigation (Mootz, 1995).
    With the profession's increasing involvement in critical investigation and professional improvement, the label of chiropractic as an unscientific cult has difficulty sticking. Research has demonstrated that manipulation, a primary mode of care for the doctor of chiropractic, is effective in the treatment of acute low back pain (Shekelle, 1992). The inclusion of manipulation as a recommended treatment in the Federal guidelines for the treatment of acute low back pain is the result of the findings of researchers both within and outside of chiropractic (Bigos, 1994). As research evaluates the value of chiropractic for other clinical problems, the capabilities and limitations of chiropractic care will become more apparent, appropriate interdisciplinary relationships will be established and patient care will be improved.
    It has taken 100 years of self-directed, bootstrap efforts utilizing internal funds to bring chiropractic into the mainstream of health care. As a mainstream provider, the issues of role and

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scope of practice are now receiving serious attention. Is chiropractic an alternative to medicine? Is there a complementary role that includes collaborative care? Should chiropractic remain a separate and distinct profession or seek inclusion into medicine as a subspecialty in musculoskeletal conditions? Should chiropractic education seek affiliation with major universities housing medical education? Answers to these questions will have a significant effect on the future of chiropractic education and practice.

References

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services, December 1994.

Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching, 1910.

Fuller RC. Alternative Medicine in American Religious Life. New York, NY: Oxford University Press, 1989.

Gevitz N. "A coarse sieve": basic science boards and medical licensure in the United States. J Hist Med & Allied Sci 1988;43:36-63.

Gibbons RW. Physician-chiropractors: medical presence in the evolution of chiropractic. Bull Hist Med 1981;55(2):233-45.

Keating JC, Mootz RD. The influence of political medicine on chiropractic dogma: implications for scientific development. J Manipulative Physiol Ther 1989;12(5):393-8.

Keating JC, Rehm WS. The origins and early history of the National Chiropractic Association. J Can Chiropr Assoc 1993;37(1):27-51.

Mootz RD, Haldeman S. The evolving role of chiropractic within mainstream health care. Top Clin Chiropr 1995;2(2):11-21.

Palmer DD. The Chiropractor's Adjuster: A Textbook of the Science, Art and Philosophy of Chiropractic for Students and Practitioners. Portland, OR: Portland Printing House, 1910.

Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med 1992;117(7):590-8.

Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books Inc., 1982. Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis, MO: Mosby Year Book, 1992, Chapters 6 and 8.

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