This is the third paper in a series that explores the historical events surrounding the Wilk v American Medical Association (AMA) lawsuit in which the plaintiffs argued that the AMA, the American Hospital Association, and other medical specialty societies violated antitrust law by restraining chiropractors' business practices. The purpose of this paper is to provide a brief review of the history of the growth of chiropractic, its public relations campaigns, and infighting that contributed to the events surrounding the Wilk v AMA lawsuit.
This historical research study used a phenomenological approach to qualitative inquiry into the conflict between regular medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. Our methods included obtaining primary and secondary data sources. The final narrative recount was developed into 8 papers following a successive timeline. This paper is the third of the series that explores the growth the chiropractic profession.
By the 1930s, the AMA was already under investigation for violation of antitrust laws and the National Chiropractic Association was suggesting that the AMA was establishing a health care monopoly. Chiropractic schools grew and the number of graduates rose quickly. Public relations campaigns and publications in the popular press attempted to educate the public about chiropractic. Factions within the profession polarized around differing views of how they thought that chiropractic should be practiced and portrayed to the public. The AMA leaders noted the infighting and used it to their advantage to subvert chiropractic.
Chiropractic grew rapidly and established its presence with the American public through public relations campaigns and popular press. However, infighting would give the AMA material to further its efforts to contain and eliminate the chiropractic profession.
Chiropractic grew quickly in the first part of the 20th century despite experiencing many challenges. There were multiple factions and leaders who were passionate about their own views of what the chiropractic profession was and what chiropractic should be. As well, strong opposition from the American Medical Association (AMA) developed substantial hurdles for the fledgling profession. Public perception of chiropractic was important as it was a driving force that helped support chiropractic legislation. Both medicine and chiropractic had public relations campaigns, including publications in the popular press that attempted to sway the thoughts of the American public. The battle for the public's opinion about chiropractic contributed to shaping the direction of the profession.
Since its beginning in 1847, the AMA had declared any health profession that was not “regular medicine” was quackery and endeavored to control its competition. Although medicine's opposition had been consistent and longstanding, events in the 1950s may have tempted the AMA to amplify its attack against chiropractic in the next decade. These events included (1) the growth in the number of chiropractors, (2) the expansion of chiropractic scope of practice, (3) the increasing popularity of chiropractic, and (4) the ever-increasing boldness of chiropractors to speak out against medicine. As a result, the AMA leaders strengthened their efforts and developed increasingly aggressive attacks, which ultimately led chiropractors to file the Wilk v AMA lawsuit.1
The historical events surrounding this lawsuit are important for chiropractors today because they help explain the surge in scientific growth2–21 and the improvement in access to chiropractic care for patients once barriers were removed.22–35 These events clarify chiropractic's previous struggles and how past experiences may influence current events. The obstacles and challenges that chiropractic overcame may help explain the current culture and help to identify issues that the chiropractic profession may need to address in the future.
The purpose of this paper is to provide a brief review of the history of the growth of chiropractic, its public relations campaigns, and infighting that contributed to the events surrounding the Wilk v AMA lawsuit. This paper describes the rise in the numbers of chiropractors in the United States and discusses some of the chiropractic infighting that the AMA would later use as a wedge to undermine chiropractic advancement.
This historical study used a phenomenological approach to qualitative inquiry into the conflict between regular (orthodox) medicine and chiropractic and the events before, during, and after a legal dispute at the time of modernization of the chiropractic profession. The metatheoretical assumption that guided our research was a neohumanistic paradigm. As described by Hirschheim and Klein, “The neohumanist paradigm seeks radical change, emancipation, and potentiality, and stresses the role that different social and organizational forces play in understanding change. It focuses on all forms of barriers to emancipation - in particular, ideology (distorted communication), power, and psychological compulsions and social constraints - and seeks ways to overcome them.”36 We used a pragmatic and postmodernist approach to guide our research practices, such that objective reality may be grounded in historical context and personal experiences and interpretation may evolve with changing perspectives.37
We followed techniques described by Lune and Berg.38 These steps included identifying the topic area, conducting a background literature review, and refining the research idea. After this we identified data sources and evaluated the source materials for accuracy. Our methods included obtaining primary data sources: written testimony, oral interviews, public records, legal documents, minutes of meetings, newspapers, letters, and other artifacts. Information was obtained from publicly available collections on the internet, university archives, and privately owned collections. Secondary sources included scholarly materials from textbooks, and journal articles. The materials were reviewed, then we developed a narrative recount of our findings.
The manuscript was reviewed for accuracy, completeness, and content validity by a diverse panel of experts, which included reviewers from various perspectives within the chiropractic profession ranging from broad-scope (mixer) to narrow-scope (straight) viewpoints; chiropractic historians; faculty and administrators from chiropractic degree programs; corporate leaders; participants who delivered testimony in the trials; and laypeople who are chiropractic patients. The manuscript was revised based on the reviewers' feedback and returned for additional rounds of review. The final narrative recount was developed into 8 papers that follow a chronological storyline.39–45 This paper is the third of the series that considered events relating to the lawsuit that transformed the chiropractic profession and explores chiropractic development in the mid-20th century and infighting within the profession.
Early Recognition of AMA Antitrust Actions
By the 1930s, the actions of organized medicine against other professions had been noticed by the federal government. The US Department of Justice investigated the AMA regarding claims that it was in violation of antitrust laws.46 The national chiropractic associations were aware that organized medicine was gaining control over health care in the United States. As early as 1938, the National Chiropractic Association (NCA) pointed out the concern for AMA dominance. The author of a cartoon claimed that this would be at the expense of the public's health and result in greater suffering of humanity (Fig. 1).47
Chiropractic Growth in the United States
Despite the hostile environment, by midcentury the chiropractic profession continued to grow. The GI bill that followed World War II covered tuition for chiropractic programs for those returning from military service. Thousands of veterans took advantage of these grants to pursue a chiropractic career.48 Increasing numbers of chiropractic graduates spread across the country. At the same time, the quality of chiropractic education improved, and the chiropractic profession made progress on establishing its own professional accrediting agency so that students could receive federal loans. The NCA saw that expanding chiropractic scope allowed chiropractors to provide a wider variety of services to the public and was an opportunity to expand how chiropractic could serve the public. However, political medicine continued its campaign to contain any expansion (Fig. 2).49
The NCA (which became the present-day American Chiropractic Association [ACA] in 1963) continued to press for legislation to expand the scope of chiropractic practice to include other modalities and practices in addition to adjusting chiropractic vertebral subluxations by hand. This push for expansion of chiropractic scope was seen as threatening to organized medicine. The AMA was paying attention to chiropractic and the subsequent medical discussions became more frequent about what to do about the “chiropractic problem.” The AMA leaders noticed that efforts from state and national chiropractic associations to establish chiropractic as a separate and distinct profession was showing success (Fig. 3).50
As more states legally recognized the chiropractic profession, chiropractic grew into the territories that organized medicine perceived to be its own. Because chiropractic was becoming a licensed profession, chiropractors practiced in those states without fear of prosecution regarding licensure. The profession that the AMA had earlier considered as a mere nuisance was becoming a more serious concern by the 1950s.51 If elimination was the desired outcome, the AMA seemed to have missed their opportunity to squelch chiropractic prior to the 1920s (Fig. 4) 52 since that was the decade that appeared to have been the pivotal time for chiropractic growth in the United States. Yet even with chiropractic growth, orthodox medicine remained dominant. By 1962, there were only about 12,000 to 14,000 licensed chiropractors compared to 250,000 medical doctors in the United States.
During the 1950s, leaders of both the International Chiropractors Association (ICA) and the NCA were aware of the continued efforts of the AMA to use its anti-quackery campaign to control health care in general. The October 1954 International Review of Chiropractic carried a critical analysis of an article published in The Yale Law Review on medical monopoly practices of the AMA.53
Skirmishes between medicine and chiropractic were becoming more common. Leaders from the NCA criticized the AMA's actions and policies in the Journal of the National Chiropractic Association. The AMA released a pamphlet about quacks in 1955 and the NCA ridiculed the AMA's attempts to root out quacks from the medical profession. The chiropractic article concluded by saying, “The AMA should be congratulated for bringing to the attention of the general public the dire need of a house-cleaning in the medical profession, and it behooves us as interested citizens to help spread this information to innocent people who are being bilked of their money.”54
Chiropractic Public Relations Campaigns
Throughout the 1950s, the AMA continued its attack on chiropractic in the public media. During this time, the chiropractic profession worked diligently to create its own marketing plans to enhance the legitimacy of chiropractic in the eyes of the American public. The ICA, the NCA, and the Canadian Chiropractic Association collaborated by holding joint conferences to enhance public relations for chiropractic.55,56 Chiropractic public relations programs included mass media, meetings with elected officials, and large-scale public education campaigns.57 These efforts included distributing information about how chiropractors could contribute in areas that organized medicine opposed chiropractic involvement. Two such areas were industrial and labor relations and chiropractic inclusion in the care of veterans through the US Department of Veterans Affairs.58
Chiropractic leaders knew that mass media was an effective marketing vehicle. They developed a national television series including celebrity spokespersons designed to raise the prestige of chiropractors in the eyes of the public.59 This series was first broadcast throughout the state of Iowa, the home of the NCA, the ICA, and the Iowa State Medical Society.59 The NCA released a Hollywood-produced movie about chiropractic for television broadcasting and radio recordings.60 Media coverage included broadcasts from CBS, Fox Movietone, and television talk shows.61
The national chiropractic associations encouraged chiropractors to inform local newspapers and radio stations of potential events of intrigue.60,62 They befriended radio, television, and newspaper reporters to disseminate chiropractic materials to the public,62 and local newspaper reporters to get the best coverage of chiropractic events.60 One director of public relations outlined procedures that chiropractors should follow when handling reporters for local and state meetings, including invitation etiquette, making reporters feel welcome at meetings, and other gestures of distinction.62 The NCA had a news service that promoted chiropractors who spoke nationally and that disseminated information about national conventions.
Elected officials were targeted to promote chiropractic. The NCA was successful in promoting an annual National Chiropractic Day on September 18, the day that DD Palmer was said to have performed the first chiropractic adjustment and thereby founding chiropractic (Fig. 5). For this day, the NCA recruited politicians to issue proclamations of National Chiropractic Day. Mayors, senators, and congressmen extolled the benefits of chiropractic in speeches, including in the US House of Representatives, and official proclamations, such as in the Congressional Record.63–65
The NCA urged chiropractors to appeal to both old and young Americans to share the benefits of chiropractic.66 In 1955, the NCA distributed a series of educational advertisements called The Truth about Chiropractic, which described the popularity of chiropractic with Americans, the numbers of patients with diseases helped by chiropractic, and the breadth of inclusion of chiropractic in insurance companies and occupational injury programs (Fig. 6).67,68 These publications likely rankled the leadership of the AMA.
Chiropractic Popular Press
The NCA did their best with their limited resources, which faced the AMA's public relations budget, which was $400,000 in 1958.69 The NCA developed programs to educate through the popular press. For example, an issue of McCall's magazine (October 1959) published “The Case for Chiropractors!”70 that promoted chiropractors as health providers. Other articles represented chiropractors as experts in topics such as slipped disk, nervous tension, and other health-related issues, which challenged the AMA's position.71
In a combined effort, the NCA and ICA attempted to convince the public that a chiropractor was able to take care of all health concerns. A mass-produced book, Your Health and Chiropractic, stated that it contained “The Complete True Story of America's Fastest Growing and Most Controversial Healing Art.” The book was written for the lay public and purposely addressed controversial topics. Issues included explanations for why medicine was opposed to chiropractic and mentioned “organized medicine's private war against chiropractic.” This book also contained pictures of a patient receiving chiropractic adjustments.72
To increase outreach to the public, the NCA published a chiropractic magazine for the layperson, which was similar in concept to the AMA's magazine Hygiea. More than 146,000 copies of Healthways were published each month. Healthways clubs, consisting of laypeople, were formed. Club members could use the magazine to discuss community health issues promoted by the NCA. Each club member would pay $1 in dues and the NCA provided an annual subscription of Healthways through the members' chiropractor, a personalized club membership card that the chiropractor could give to each member, and a club certificate that could be mounted in the chiropractors' office where club meetings were held (Fig. 7).73,74
The NCA Proclaims a New Definition of Chiropractic
In 1958, the NCA had the largest membership of any chiropractic organization, which included nearly 8000 chiropractors and chiropractic students combined.73 Considering that by 1960 there were just over 14,000 chiropractors in the United States,51 the NCA members comprised nearly 60% of the profession. Given this majority, successful implementation of the new NCA plans had the potential to secure substantial social influence in the United States.
The NCA proclaimed 1958 as “The Year of Decision”73 and declared NCA's integrated master plan to broaden the scope of chiropractic practice and to further promote chiropractic to the public. The goals included legislative activities, public relations campaigns, and growing the membership of the NCA. The purpose of this plan was to create a new national definition of chiropractic and scope of practice.69
This program aimed to socially legitimize and publicize the new vision of chiropractic, which included state-by-state lobbying with legislators to change licensure laws to include the NCA definition of chiropractic. The NCA hoped that passing such legislation throughout the United States would create a more uniform definition of chiropractic. The NCA also sought to standardize educational requirements for licensing in all states.69,73 The announcement of the NCA's new definition and aim to increase the scope of practice was not supported by the ICA.
Infighting and Attempts at Unity Between Chiropractic Associations
Disputes between the ICA and the NCA continued. The NCA legal counsel lamented that the lack of uniformity within chiropractic was a primary reason why the public did not understand chiropractic and that such disparity was “symptomatic of professional and organizational immaturity.”75 The NCA lawyer went on to say that chiropractic was part of the health care system:
Thus it is well established from a legal point of view that the practice of medicine includes the practice of allopathy, osteopathy, and chiropractic. Those who insist that chiropractic is not in any sense the practice of medicine have failed to present any substantial or persuasive reasons why this obsolete position should be maintained by the profession. I see no violence done to the profession or its principles by statutory or judicial reference to it as ‘chiropractic medicine' or to its doctors as ‘chiropractic physicians.'75
The ICA expressed different views about how chiropractic should be represented, which were in direct opposition to the NCA. The ICA stance wished to preserve the distinction between the profession of chiropractic and medicine and avoid any real or implied overlap with medical scope of practice.
Despite longstanding disagreements between some ICA and NCA officers, leaders of the ICA and NCA began discussing the possibility of unifying the 2 organizations into a single national chiropractic organization that represented all chiropractors in the United States.76–79 Their plans were widely published in the Journal of the NCA and the International Review of Chiropractic during 1962–1963. The plan was to create a new combined association, which would be named the American Chiropractic Association (ACA).
During these negotiations, the ICA proposed a definition and scope of chiropractic, which stated, “Chiropractic is the science which deals with the relationship between the articulations of the human body (especially the spine) and the nervous system and the role of these relationships in health and disease.” And, “Scope of Practice – The practice of chiropractic consists of the use of accepted scientific procedures for the purpose of locating, analyzing, corrections and adjusting the interference with nerve transmission and expression (especially of the spinal column) without prescribing drugs or performing operative surgery and to work in cooperation with all branches of the healing arts in order to make the best provisions for the benefits of chiropractic to the public.”80 The NCA rejected these proposed statements.
The NCA counterproposed a definition and scope of chiropractic, which the ICA rejected, that stated, “Chiropractic is a science of healing based on the premise that disease is caused by the abnormal functioning of the human nervous system,”73 and also included,
The practice of chiropractic consists of the diagnosing of human ailments by the use of all diagnostic procedures recognized by the various schools of the healing arts; the elimination of the abnormal functioning of the human nervous system by the adjustment of the articulations and adjacent tissue of the human body, particularly of the spinal column; the use, as indicated, of procedures which make the adjustment more effective, including clinical nutrition, psychotherapy and physiotherapy, but excluding the use of drugs and surgery.80
After years of difficult negotiations, the 2 organizations conceded that they were not able to come to a resolution to merge.77 After the debates that led to the dissolution of the NCA–ICA unification, some ICA members defected to the NCA. In late 1963, the NCA, new member recruits, and defectors from the ICA became the ACA.76,81 The new ACA represented the majority of the chiropractors in the early 1960s.76 Members who remained with the ICA became increasingly vocal in their opposition to the new ACA's activities.
The major factions within the chiropractic profession polarized around differing views of how they thought that chiropractic should be portrayed to the public. The AMA noted the infighting within chiropractic and used this information to its advantage to subvert chiropractic, which would later be revealed during the Wilk v AMA lawsuit.
The growth of chiropractic continued. By the time the AMA began to recognize that there was what they called a “chiropractic problem,” the number of chiropractors was substantial and a positive public perception of chiropractic as a health care option had already been established. The AMA and local medical societies observed the NCA's push for wider scope of practice and the chiropractic profession's efforts to raise the public's perception of chiropractic, which were perceived as threats.
Chiropractic schools grew and the number of graduates expanded as the GI bill helped to fund the education of service members returning from the war. Since chiropractors were not part of the medical healthcare system, the AMA would not allow them in medical hospitals; therefore, chiropractors had to resort to other means of informing patients about what chiropractic care could do. Increasing efforts to educate the public about what chiropractic care offered resulted in public health campaigns.
The chiropractic profession had various viewpoints of how to apply the art of chiropractic in practice. From the early years of development emerged 2 general views. This division would be used by the AMA to cripple chiropractors' efforts to create a protective stance. The lead attorney for the plaintiffs, Mr George McAndrews, described these 2 views of chiropractic in his opening statements to the jury during the first trial:
The straights have limited their practice by desire to manual manipulation of the spinal column and its related articulations. Those are on or near the spine. Ten finger laws, they call them. Some of the states require that. They use no or very few additional modalities.
A mixer takes that ten fingers and adds to it — the term “mixing,” adds to it this terminology. They utilize the physiotherapeutic modalities. In addition to their hands they will use such additional modalities as heat, hot packs, cold, ice packs, or electrical stimulation and light ... In many states they will give nutritional counseling ... They will perform a broader service than merely hand manipulation.82
Chiropractic was a young profession with a divided house. The ICA and NCA competed for members and thus tried to create their own unique brand of chiropractic. As more chiropractors graduated, the profession grew, which meant that the competing chiropractic factions also grew. Communications and actions from the differing national associations fought against each other attempting to gain a dominant role and competing for members. Chiropractic factions also competed against each other regarding legislation. This lack of unity and differing messages often left those in the US government, policy makers, and the public confused.
The AMA noticed the infighting and considered chiropractors' unwillingness to establish a common front as a weakness. The AMA leadership used this information to attempt more aggressive and clandestine methods to contain and eliminate the chiropractic profession in the years ahead.
This historical narrative reviews events from the context of the chiropractic profession and the viewpoints are limited by the authors' framework and worldview. Other interpretations of historic events may be perceived differently by other authors. The context of this paper must be considered in light of the authors' biases as licensed chiropractic practitioners, educators, and scientific researchers.
The primary sources of information were written testimony, oral interviews, public records, legal documents, minutes of meetings, newspapers, letters, and other artifacts. These formed the basis for our narrative and timeline. We acknowledge that recall bias is an issue when referencing sources, such letters, where people recount past events. Secondary sources, such as textbooks, trade magazines, and peer-reviewed journal articles, were used to verify and support the narrative. We collected thousands of documents and reconstructed the events relating to the Wilk v AMA lawsuit. Since no electronic databases exist that index many of the publications needed for this research, we conducted page-by-page hand searches of decades of publications. While it is possible that we missed some important details, great care was taken to review every page systematically for information. It is possible that we missed some sources of information and that some details of the trials and surrounding events were lost in time. The aforementioned potential limitations may have affected our interpretation of the history of these events.
Some of our sources were interviews, manuscripts, or letters where the author recalled past events. Recall bias is an issue when referencing interview sources. Surviving documents from the first 80 years of the chiropractic profession, the years leading up to the about the Wilk v AMA lawsuit are scarce. Chiropractic literature existing before the 1990s is difficult to find since most of it was not indexed. Many libraries have divested their holdings of older material, making the acquisition of early chiropractic documents challenging. While we were able to obtain some sources from libraries, we also relied heavily upon material from our own collection and materials from colleagues. Thus, there may be relevant papers or artifacts that were inadvertently missed. Our interpretation of the events related to the trials is limited to the materials available. The information regarding this history is immense and due to space limitations, not all parts of the story could be included in this series.
Chiropractic grew rapidly and established a presence with the American public through public relations campaigns and popular press. These activities, the increasing numbers of chiropractors, and scope of chiropractic practice, raised the AMA's concern about chiropractic. However, infighting between chiropractic associations gave the AMA opportunities to further its efforts to contain and eliminate the chiropractic profession.
We thank the following people for their detailed reviews and feedback during development of this project: Ms Mariah Branson, Dr Alana Callender, Dr Cindy Chapman, Dr Gerry Clum, Dr Scott Haldeman, Mr Bryan Harding, Mr Patrick McNerney, Dr Louis Sportelli, Mr Glenn Ritchie, Dr Eric Russell, Dr Randy Tripp, Mr Mike Whitmer, Dr James Winterstein, Dr Wayne Wolfson, and Dr Kenneth Young.
FUNDING AND CONFLICTS OF INTEREST
This project was funded, and copyright owned by NCMIC. The views expressed in this article are only those of the authors and do not reflect the official policy or position of NCMIC, National University of Health Sciences, or the Association of Chiropractic Colleges. BNG is the editor-in-chief of the Journal of Chiropractic Education and CDJ is on the NCMIC board and the editorial board of the Journal of Chiropractic Education. No other conflicts of interest were reported.
Claire Johnson, DC, MSEd, PhD, has been a licensed chiropractor for 30 years and is the editor in chief for 3 scientific journals, Journal of Manipulative and Physiological Therapeutics, Journal of Chiropractic Medicine, and Journal of Chiropractic Humanities. She has decades of experience publishing in the fields of clinical and historical research and is a professor at the National University of Health Sciences. The daughter of a medical physician, she grew up in the San Francisco Bay Area, where she witnessed the conflicts between medical and chiropractic providers and wondered why such tensions existed. One of her passions has been to try to unravel this mystery and find a way forward. Her work with interprofessional relationships has included coordination of a team of international spine experts that developed an evidence-informed spine care model for communities around the world. Her master's degree in health professions education and public health doctorate contribute to her expanded worldview and greater understanding of the interconnectivity of this important historical subject, including the impact of this trial on chiropractic, patients, and the public. Claire Johnson is a professor at the National University of Health Sciences (200 E. Roosevelt Rd, Lombard IL 60148; email@example.com).
Bart Green, DC, MSEd, PhD, provides chiropractic care in an interdisciplinary, on-site corporate health center in San Diego and is a faculty member at the National University of Health Sciences. He has developed doctorate courses in the domains of chiropractic history and clinical education at several chiropractic programs. He is the editor in chief of the Journal of Chiropractic Education. He was raised in the Los Angeles area, where he observed health disparities and the need for both medical and chiropractic care to be made more available for underserved populations. He is a skilled communicator and has experience navigating the complexity of interprofessional collaborative relationships in the medical health care environment. He served on the medical staff at Naval Medical Center San Diego in interprofessional spine, sports, and combat casualty care clinics, providing chiropractic care to active-duty military members. He has taught in clinical settings training chiropractors, chiropractic students, medical students, nursing students, residents, physician assistant students, and Navy corpsmen. Bart Green is a lecturer at the National University of Health Sciences (200 E. Roosevelt Rd, Lombard IL 60148; firstname.lastname@example.org).
Concept development: CDJ, BNG. Design: CDJ, BNG. Supervision: CDJ. Data collection/processing: CDJ, BNG. Analysis/interpretation: CDJ, BNG. Literature search: CDJ, BNG. Writing: CDJ, BNG. Critical review: CDJ, BNG.