Articles by JCS

New Zealand Report

Indeed it is probably true to say that

     chiropractic is a form of treatment    

still in search of an explanation for its effectiveness. [1]

Royal Commission of Inquiry into Chiropractic

 

Spot on Down Under

 

Just two years after the Wilk trial began and half-way around the world, the New Zealand government convened a Royal Commission of Inquiry into Chiropractic in 1978-79 headed by Mr. BD Ingles, QC, BA, JD, and LL.D as Chairman. Counselors and leaders from the main New Zealand stakeholders participated: the Medical Association, the Society of Physiotherapists, the Chiropractors’ Association, the Department of Health, and the Consumer Council were involved in this investigation as to whether or not chiropractic services should be included in its national healthcare services.

In 1975 a petition signed by 94,210 citizens was presented to Parliament asking that “Chiropractic services be subsidized under Social Security and Accident Compensation, so that patients of Registered Chiropractors may receive their services on the same basis as they receive other Health services with the community.” In July 1976 the then Minister of Health announced the Government’s decision to establish a Commission of Inquiry into Chiropractic.[2]

This Commission conducted unquestionably at the time the most thorough and fair investigation into the chiropractic profession in the world, seeking input from the major players, the public, and renowned scientists.

According to a report by Kevin Drew:

There were 136 formal submissions made to the Commission, coming to more than 2,300 pages. Oral evidence amounted to 3,658 pages of transcript presented over a period of 78 days (CIC 179:15). In addition, the Commission received nearly 13,000 completed questionnaire forms from chiropractic patients…The Commission visited the medical schools at Otago and Auckland and the schools of physiotherapy in Auckland and Dunedin. In addition, chiropractic colleges were inspected in Australia, England, Canada and the United States.[3]

Obviously no leaf was left unturned in this two-year investigation. As the Commission admitted:

The matters with which we had to deal were therefore difficult, both because of their substance and because of their emotional overtones. A careful approach was required. We would need solid facts and concrete evidence.[4]

Unlike the Wilk trial that dealt primarily with the illegal antitrust activity of the AMA toward chiropractic in the USA, this Commission dealt with the social, political, and scientific aspects of chiropractic care, which George McAndrews as lead attorney for Wilk also used in his courtroom evidence but to a lesser degree. In effect, this inquiry revealed the same medical prejudice sown by Morris Fishbein decades before and illustrate by testimony from the Medical Association’s witnesses. As the Commission found, the tentacles of the Medical Mussolini were now worldwide.

The New Zealand Commission discussed these controversial issues head-0n in what has to be considered the most even-handed analysis ever done on the chiropractic and medical war and its findings were shocking to the medical antagonists.

At the beginning of this investigation the Commission admitted its own naiveté and prejudice:

We entered upon our inquiry in early 1978. We had no clear idea of what might emerge. We knew little about chiropractors. None of us had undergone any personal experience of chiropractic treatment. If we had any general impression of chiropractic it was probably that shared by many in the community: that chiropractic as an unscientific cult, not to be compared with orthodox medicine or paramedical services. We might well have thought that chiropractors were people with perhaps a strong urge for healing, who had for some reasons not been able to get into a field recognized by orthodox medicine and who had found an outlet outside the fringes of orthodoxy.

But as we prepared ourselves for this inquiry it became apparent that much lay beneath the surface of these apparently simple terms of reference. In the first place, it transpired that for many years chiropractic had been making strenuous efforts to gain recognition and acceptance as members of the established health care team. Secondly, it was clear that organized medicine in New Zealand was adamantly opposed to this on a variety of grounds which appeared logical and responsible. Thirdly, however, it became only too plain that the argument had been going on ever since chiropractic was developed as an individual discipline in the late 1800s and that in the years between then and now the debate had generated considerably more heat than light.[5]

            And light is definitely what this Commission shined on this debate unlike any group other than the legal team for the chiropractic-plaintiffs at the Wilk trial.

 

Unproven Theory of Disease

The medical opposition simply parroted Morris Fishbein and the AMA’s Committee on Quackery succinctly in the opening address of leading counsel for the New Zealand Medical Association, Mr. JT Eichelbaum, QC, when he said chiropractic was “absurd,” “unproven,” and will be “completely discredited” (Transcript, p. 1729):

The root cause of the opposition of organized medicine is quite simply stated. It is that the basis of chiropractic’s theory of the cause of disease which is unproven and, in the minds of many thoughtful medical scientists, absurd. Not only that, but the theory is shackled to a single modality of treatment which is also unproven…it is the firm belief of medicine that the theory of disease on which chiropractic is founded will never be proven; that it is incapable of proof; and that in the end it will be completely discredited, if indeed that is not already the position.[6]

The Commission concluded that the medical view of chiropractic is “understandable but unjustified” allthewhile “ignoring its now well-demonstrated useful contributions to health care.”

The “unproven theory of disease” objection is understandable. Many early chiropractic writings, and some in more recent times, make outrageous claims and draw sweeping conclusion on the slenderest evidence while those less responsible in the profession continue to make such claims, the orthodox medical attitude remains understandable but unjustifiable. It is very convenient for a medical practitioner to make the simple decision to reject chiropractic as a whole on the basis of its greatest weaknesses, while ignoring its now well-demonstrated useful contributions to health care. The fact that it remains outside orthodox medicine is probably sufficient reason for most doctors to banish it.

The more the Commission investigated this negative attitude by the Medical Association, the more it found irony in its stance of accusing chiropractic of being unproven and absurd. In fact, the Commission quoted from a medical expert who noticed patients often voted with their feet in regards to their choice of practitioner.

In the words of JF Bourdillon, author of Spinal Manipulation (2nd ed. London, 1975, pp. 9-10),  

“The medical profession claims that the healing art is its own exclusive province but unfortunately, the general public does not agree. There will always be the ‘odd man out’ who will tend to seek treatment from an unorthodox practitioner for reasons that are often quite inadequate, but the present position is that many of the public can obtain relief from unorthodox practitioners of manipulative therapy when they do not get the same relief from the orthodox profession.”[7] (emphasis added)

Indeed, the more light shined on this inquiry by the Commission led to revelations that were judicious and insightful — something the Medical Association never had done in its lengthy war on chiropractors. In fact, the Commission commented on the “remorseless and unrelenting opposition” of chiropractic by the medical society:

We pause at this point. Chiropractors have for years been claiming that chiropractic treatment may be and in some cases is beneficial for the type of [visceral/organic] disorder we have mentioned. Yet it is astonishing to find that little if any constructive effort has been made by the medical profession to investigate these claims. In the face of that neglect it would appear unreasonable that organized medicine should be so bitterly and adamantly opposed to chiropractic. The approach of organized medicine to chiropractic is not one of detached scientific interest and curiosity about a form of treatment that appears to have helped by a large number of patients. This is an approach which might have been expected; but instead it has been one of remorseless and unrelenting opposition. [8] (emphasis added)

The findings by the Commission also were just the opposite of their first Fishbein-laden bias that chiropractic was an “unscientific cult” and confessed that “Anyone who attempts to judge modern chiropractors by what was written or taught about chiropractic in the early 1900s will obtain a wholly misleading picture of what chiropractic is today.”[9]

Summary of Principle Findings[10]

General

  • Modern chiropractic is far from being an “unscientific cult.”
  • Chiropractic is a branch of the healing arts specializing in the correction by spinal manual therapy of what chiropractors’ identity as biomechanical disorders of the spinal column. They carry out spinal diagnosis and therapy at a sophisticated and refined level.
  • Chiropractors are the only health practitioner who are necessarily equipped by their education and training to carry out spinal manual therapy.
  • General medical practitioners and physiotherapists have no adequate training in spinal manual therapy, though a few have acquired skill in it subsequent to graduation.
  • Spinal manual therapy in the hands of a registered chiropractor is safe.
  • The education and training of a registered chiropractor are sufficient  to enable him to determine whether there are contra-indications to spinal manual therapy in a particular case, and whether the patient should have medical care instead of or as well as chiropractic care.
  • Spinal manual therapy can be effective in relieving musculo-skeletal symptoms such as back pain, and other symptoms known to respond to such therapy, such as migraine.
  • In  a limited number of cases where there are organic and/or visceral symptoms, chiropractic treatments may provide relief, but this is unpredictable, and in such cases the patient should be under concurrent medical care if that is practicable.

The Commission understood that the actions of the AMA were “unjustifiable” and the “ethics of medical practice in the United States were themselves far from beyond criticism”. The Commission also laid blame on the warfare between organized medicine and the chiropractic profession on three main reasons that annoyed the medical establishment:

The attitude of the medical profession in the United States can be understood although it is clear that at that time the general standards and ethics of medical practice in the United States were themselves far from beyond criticism. But chiropractors did not improve their own image among orthodox medical practitioners. First, they drew in patients. Secondly, they claimed cures which orthodox doctors considered impossible. Thirdly, they tended to advertise their treatment and its results to a degree which must have acted as a severe irritant.[11] (emphasis added)

Slipped Discs vs. Slipped Joints

Another contentious issue for the medical society concerning chiropractic was their inability to understand the scientific nature of the “vertebral subluxation”, a termed coined by early chiropractors that is equivalent to what medical professionals such as Scott Haldeman, DC, MD, PhD, call a “manipulatable lesion”.[12]

The Commission recognized the bias of the medical profession to this dynamic concept of joint dysfunction as the basis of the chiropractic subluxation.

It is clear that the general concept of the “chiropractic subluxation” is not accepted by medical practitioners. They do not consider it of any significance or importance, and appear to have dismissed it out of hand.[13]

Although the Medical Association claimed that vertebral subluxations are imaginary, the Commission found there to be a “difference between structural and functional deficiencies in a joint,” an issue ignored by the medical society.

In this inquiry the medical association took a direct view of the matter. It was argued that “chiropractic subluxation” exist only in the chiropractor’s imagination. In making this assertion the medical association relied on two main propositions. As we understood them they may be summarized in this way: first, chiropractors have never established by an acceptable scientific means exactly what a “chiropractic subluxation”  is, or how it could have the effects chiropractors claim for it; and, secondly, that the existence of a “chiropractic subluxation” cannot be verified by any orthodox means, particularly by x-ray. [14]

The chiropractors answer this argument by saying that medical practitioners do not understand the essential character of a “chiropractic subluxation”. To appreciate the point we must explain what the chiropractors see as the difference between structural and functional deficiencies in a joint. (emphasis added)

The Commission was introduced to the chiropractic paradigm of joint dysfunction rather than the medical paradigm of disc abnormalities as the cause of back pain. In fact, the Commission was ahead of researchers on this point since it would not be until over a decade later in the 1990s when medical researchers with the use of MRI scans would finally admit that disc abnormalities were commonplace in asymptomatic people and that the Dynasty of the Disc would be disproven as the main cause of back pain as explained in an upcoming chapter.

When the chiropractor uses the term “subluxation”, however, he is referring principally to a functional defect in a joint. The joint may look normal on an x-ray plate. There may be no perceptible misalignment of structural abnormality. But when the joint is examined as it is put through its ranges of motion, it may be found that there is either an abnormal limitation of movement (“fixation”), or an abnormal excess of movement (“Hypermobility”), or some other functional abnormality. These abnormalities in joint action may be apparent when the joint is put through one particular arc of movement, but not when it is put through another. The possibilities are wide.

So the chiropractor on the one hand and the medical practitioner on the other have different emphasis. In examining a suspect joint, by palpation, radiography, or other means the chiropractor is looking primarily for some abnormality in function. He will not necessarily expect to find a structural component, because a functional abnormality need not involve structural abnormality. By the same token a structurally abnormal joint may function perfectly well, although it is common sense to suppose that a structural fault will in most cases be accompanied by some functional deficiency. The point is that structural and functional deficiencies need not necessarily run in harness.[15]

TR Yochum, DC, was also able to explain clearly to us what the technique of chiropractic adjustment involved in terms of movement. He told us (Transcript, p. 3191):

The movements of vertebra in my opinion are millimetric in nature—very small degree of actual movement of a segment. I do not know if I can document that. It is a matter of my expertise, and training, and experience as a chiropractor and as specialist in x-ray. I believe even though the movement is millimetric in nature it is of centimeters in significance in that it does not take more than a few millimeters of derangement to affect the whole neurological complex of a motor unit in the spine. That is what creates the clinical phenomena that we treat.[16]

            Mr. RJ Craddock, leading counsel for the chiropractors’ association, summarized the elements of the vertebral subluxation to the Commission:

The concept of the subluxation which is central to chiropractic theory and practice is not inherently a complicated one, and the essential elements are clear:

  • Abnormal function in a spinal joint.
  • Neurological involvement.
  • Perhaps, but not necessarily displacement of a vertebrae.

The problem is a functional not a structural one...the abnormal function of the spine may produce a vascular involvement as well as the neurological one, and this vascular involvement, originally emphasized in osteopathy, is not accepted by chiropractors generally … the medical profession simply fails to see the direction and subtlety of the chiropractic approach towards spinal dysfunction. Because the chiropractor uses x-ray extensively the medical practitioner thinks he is looking for a gross bony change, and when the medical practitioner cannot see this on the x-ray the chiropractor is using he immediately becomes skeptical.  He might as well expect to see a limp, or a headache or any other functional problem on x-ray.[17] (emphasis added)

With this dynamic, functional approach in mind, the Commission concluded the medical opposition is an unreasonable and unscientific stance” and that “the chiropractors’ hypothesis is so far unproven. It does not mean it is invalid”.

Having weighted all the evidence we accept that chiropractors are not unreasonable in believing that through their specialized training and skill they are capable of identifying and treating functional defects in the vertebral column which others without that training or skill would not regard as significant. We consider that to deny that such functional defects can exist, and can impinge on the nervous and/or vascular systems, is, in the present state of knowledge, an unreasonable and unscientific stance. The exact nature of such defects has not yet been demonstrated; nor has the mechanism by which its apparent effects are produced. Undoubtedly chiropractors believe that there is such a condition as a chiropractic subluxation. They do so because when they apply manual therapy, supposedly to correct the subluxation, the patient’s condition in many cases improves. The fact that there is not yet any conclusive explanation of exactly what happens means nothing more than that the chiropractors’ hypothesis is so far unproven. It does not mean it is invalid. We accept, for the purposes of this inquiry, that a chiropractor is equipped by his training and skill to locate and relieve a condition which for want of a better term he calls a subluxation, and that the result of his therapy can provide relief from, at least, back pain.[18]

 Type O Disorders

The Commission wholeheartedly endorsed chiropractic care for Type M disorders (musculoskeletal disorders) and recommended these cases be referred by medical to chiropractors.

The Commission is satisfied that chiropractors are successful in the diagnosis and treatment of Type M disorders. It sees no reason why medical practitioners should not refer patients with Type M disorders to chiropractors for treatment. The official medical attitude, that no such referrals can be treated as ethical, is in the Commission’s judgment, unjustified and not in the interests of the patients. [19]

However, our view is that chiropractors are not unreasonable or “unscientific” in believing that their method of treatment may sometimes have a beneficial effect on a patient’s visceral and/or organic disorder but such cases must in the mean time be regarded as frankly experimental.[20]

Once the evidence showed the overall effectiveness of manipulative therapy done by chiropractors for Type M disorders were well-received by the public, the Commission turned to the more controversial aspect of chiropractic’s claim to help visceral/organic problems (referred to as Type O disorders).

Unquestionably, the Commission found the medical opposition and ridicule of chiropractic’s claim to help organic and visceral disorders was the most contentious disagreement. The Commission found that inability of chiropractors to explain the mechanism of improvement with Type O disorders allowed the medical society to, in effect, throw the baby out with the bathwater.

It is the chiropractors’ claims of success in treatment of the Type O category which principally strains the credulity of medical practitioners, and in their minds invalidates the whole chiropractic system.[21]

According to the Commission:

Having considered the evidence for the clinical effectiveness of spinal manual therapy, including that delivered by chiropractors, we turn now to the question of the “chiropractic theory of disease.” This may be summarized briefly in the words of the American Chiropractic Association used in their 1979 statement of the Chiropractic State of the Art”(pp. 9-10):

  1. Disease may be caused by disturbances of the nervous system.
  2. Disturbances of the nervous system may be caused by derangements of the musculoskeletal structure [especially the vertebrae and pelvis].
  3. Disturbances of the nervous system may cause or aggravate disease in various parts or functions of the body … Under predisposing circumstances, almost any component of the nervous system may directly or indirectly cause reactions within any other component by means of reflex mediation.

So the logical consequence, according to the American Chiropractic Association, is that mechanical musculoskeletal derangements (the chiropractic subluxation) of the vertebrae or pelvis and associated structures can be a contributing factor to functional disorders of organic visceral and vasomotor nature.[22]

It is to be noted that there is no claim in this summary of the disease theory that disturbances of the nervous system are necessarily a cause of any or all disease, and, if they are, that they are the only cause or even the main cause. It is also to be noted that there is no reference to the cause of pain in the back, neck or head, which, as we have reported earlier, is the reason why over 80 percent of the chiropractors’ new patients seek their help. Indeed we find chiropractors surprisingly coy about this dominant aspect of their work. We can only surmise that they regard local pain as just a manifestation of some disease state which may be of a purely mechanical nature and for which the nerve involvement is simple and direct. But we regard statements of the “disease theory” such as those we have given as relevant only to Type O chiropractic which we have earlier discussed, and therefore relevant only to a very small fraction of the chiropractors’ patients. We therefore see the final scientific testing of these theories as of much lower urgency than proofs of clinical effectiveness of spinal manual therapy, the matter discussed earlier in this chapter. Indeed, if the neurogenic disease theory were conclusively disproved this would in no way, in our view, invalidate chiropractic treatment of Type M disorders, nor would it remove the necessity for more than a small part of the chiropractor’s training.[23] (emphasis added)

Experts in neurophysiology testified to possible reasons for this phenomenon. Plus, readers must remember that in 1978-9 the mechanism of neurophysiology and functional disorders of the spine were still embryonic, as the Commission conceded, “chiropractic is a form of treatment still in search of an explanation for its effectiveness.”  Another fact not lost on the Commission was the scarcity of research by the medical profession to prove its allegations against chiropractic.

However it needs to be understood that the area of spinal mechanics and its implications in neurophysiology has not been explored by orthodox medical science. In the Commission’s view chiropractic theories have only just begun to evolve on a scientific basis both with the advent of new discoveries in neurophysiology and with the increasing number of trained scientists interested in the field.

Indeed it is probably true to say that chiropractic is a form of treatment still in search of an explanation for its effectiveness. The medical profession, with its massive research resources, has made no serious attempt to seek such an explanation and certainly has not found one. Nor has organized medicine been able to prove that chiropractic does not work. [24]

The Commission commented on the phenomenon of spinovisceral reflexes and referred pain as a “well-recognized medical phenomenon” and “an inconvenient way the nervous system has of playing tricks on the diagnostician”. As well, the Commission recognized the inability of medical practitioners to properly diagnosis these reflex disorders.

One complicating factor in any study of chiropractic is the phenomenon of referred pain. In simple terms this is pain which develops at a site remote from its actual cause. To take straightforward case, a patient may develop a dysfunction in or around particular vertebral joints which directly involves the adjacent nerves. The result is pain; but the pain appears not at the site of the vertebral dysfunction, but in the patient’s chest, indistinguishable from the pain normally associated with angina. This is well-recognized medical phenomenon. It is an inconvenient way the nervous system has of playing tricks on the diagnostician.

The illustration we have given is a simple one the phenomenon of referred pain can however appear in many other ways. In the above instance the pain was caused by a vertebral disorder: in medical terms it was vertebrogenic. But it can also work in reverse. An organic disorder, of the digestive system for instance, can make its presence felt as a pain the back: that is viscerogenic pain. Or a disorder in one part of the spinal column can show up as pain in an entirely different part of the spinal column. It is quite clear, as scientific fact, that reflex sensory input can originate from somatic or visceral sources to produce somatic and visceral effects. Sensory input from visceral sources can produce both visceral and somatic responses and somatic input may produce combined visceral and somatic responses.

The phenomenon of referred pain raises another important point. When it is vertebrogenic it can easily lead the medical practitioner into a mistaken diagnosis. For it is at this stage that his lack of training in spinal biomechanics becomes a liability.[25]

Dr. Haldeman said that 12 months’ full time training in spinal manipulative therapy following a medical degree would be appropriate.[26]

A number of medical experts told the Commission that the results chiropractors and their patients claimed in Type O cases were unlikely to be the results of spinal manual therapy. They gave a number of reasons for reaching this conclusion… However at the same time no medical expert was prepared to say that such results were impossible, simply because knowledge of neurophysiology had not advanced to a point where the possibility of such results from spinal manual therapy—however remote he might think they were—could positively be excluded.[27] (emphasis added)

According to the Commission:

Conclusive scientific testing of the Type O theory is a formidable task indeed. There are two main questions to be asked:

  1. Do mechanical dysfunctions of the spine contribute to visceral functional disorders and does removal of the mechanical dysfunction relieve the disorders?
  2. By what possible neurobiological mechanism could such mechanical dysfunctions affect visceral function?

It is much more difficult to give a scientific answer to the first (clinical) question than in the case of the simple relief of pain and musculoskeletal dysfunction which we considered earlier. It would be extremely difficult if not impossible to distinguish between different possible causes and remedies.[28]

Dr. Haldeman in his submission (Submission 131, pp. 28-33) refers to a number of reported claims by chiropractors, medical practitioners, and others that spinal manual therapy has influenced visceral function. While these claims remain contested, Dr. Haldeman concludes:

The important fact remains that practitioners of spinal manipulation throughout the world have documented similar relationships between the spinal column and visceral disease. Since there is no research by critics of chiropractic and spinal manipulation to disprove this relationship, it appears that the most unscientific posture one can take to this subject is to discard, outright by the possibility of a vertebra-visceral relationship. (p 217)

We should like to quote the views of Professor W. Kunert given at the conclusion of a review entitled “Functional Disorders of Internal Organs due to Vertebral Lesions” given at a CIBA Symposium (vol. 13, no. 3, 1965). Professor Kunert had since 1958 been working as an Oberarzt in the University medical Polyclinic in Bonn, West Germany, and included in his publications is a book entitled The Vertebral Column Autonomic Nervous System and Internal Organs, Enke, Stuttgart, 1963.

We find Professor Kunert’s remarks (p. 96) refreshingly objective and balanced:

[W]e have records of numerous cases … in which a definite connection  appears to exist between a functional disorder in an internal organ and a spinal lesion … We have no evidence that lesion of the spinal column can cause genuine organic disease. They are, however, perfectly capable of stimulating, accentuating, or making a major contribution to such disorders. There can, in fact, be no doubt that the state of the spinal column does have bearing on the functional status of the internal organs.

Dr. Haldeman (Submission 131, p. 40) remarks that these conclusions follow very closely opinions which have been expressed by chiropractors over the past 20 years.[29]

Dr. Haldeman’s (Submission 131, pp. 38-40) conveniently identified for us three neurophysiological processes which are commonly discussed when considering the effects of spinal manipulation. They are, he said:

  1. Pain physiology.
  2. Nerve compression and axoplasmic flow (flow of cellular constituents along the nerve axon).
  3. Basic reflex physiology.

In the context of the possible influence of mechanical dysfunction of the spine on visceral function we are interested in (2) and (3). This is not the place to engage in technical discussion on research in these areas but it is important to be aware that they are very active fields as indicated by documented references given by Dr. Haldeman.[30]

Nerve Compression

According to the Commission:

Nerve compression is one of the oldest and most controversial theories offered to explain the apparent influence of manual therapy on visceral function. It is now clearly established that even moderate compression of a nerve can block not only the electrical propagation of nerve impulses but also the axonal flow of protein material. This latter topic was extensively reviewed in the recent conference on Neurobiologic Mechanisms in Manipulative Therapy sponsored by the National Institute of Neurological and Communicative Disorders and Stroke at Michigan State University (Plenum, New York, 1978). Dr. Haldeman was questioned by the Commission and crossed examined by counsel at some length on this topic (Transcript, pp. 3293-6, 3335-49) and later we were able to discuss it further with members of the medical faculty at the University of Otago by arrangement with Professor GL Brinkman, Dean of the Medical School. Following this discussion Professor AJ Harris, who has been active in research and publication in this field for many years, was kind enough to write to us with his critical comments. He said:

The major point made in these sections of the transcript is that nerves can affect the tissues they innervate by a mechanism which is independent of the electrical propagation of nerve action potentials. This separate “trophic” function of nerves depends on axonal transport of materials within nerve axons.[31]

Professor Harris had written a comprehensive review of this field: see Harris, AJ. “Inductive Functions of the Nervous System”, Ann. Rev. Physiol. 36, 251-305 (1974). Professor Harris’s comment continues:

I believe that the statements made to the Commission about the existence of these mechanisms are substantially correct, but with some glossing over of the evidence… Whether the maintained application of very light pressure can block axonal transport while leaving nerve impulses intact is slightly less clear … there is no experimental evidence to support the hypothesis that pressure on a nerve could cause a dysfunction that could be expressed without there being a simultaneous and obvious block of nerve conduction, causing paralysis and sensory loss.

The Commission admitted that “active research continues on this topic and clearly the last word has not yet been said.”[32]

Reflex Physiology

The other mechanism mentioned by Dr. Haldeman involves the possible ability of manual therapy to influence reflex activity in the central nervous system. This somato-visceral reflex, in his view, holds possibly the greatest interest for those trying to establish a role for manual therapy (including chiropractic) for Type O complaints. The suggestion is that sensory input (say a chiropractic vertebral subluxation) to one part of the nervous system can influence almost any function of the nervous system.

That such reflex connections exist seems not to be in dispute. Also as we have already aid, changes in visceral function followed by spinal manual therapy have been documented. However neither a causal relation between a vertebral subluxation and visceral function nor a certain mechanism for such a vertebra-visceral reflex has been established. But clearly in the face of all the information available it is not a responsible scientific stance to assert that it is impossible for a vertebral subluxation to affect visceral function.[33]

In the course of their investigation the Consumer Council staff had received a letter from Dr RG Robinson, Director of the Neurosurgical Unit of the Dunedin Hospital, and now a professor of neurosurgery, submitted to the Commission giving a possible explanation. While hoping for an outright condemnation of the subluxation theory, Dr. Robinson described the “neurological basis of chiropractic” that appeared to support the possibility that nerve interference can be a contributing factor in Type O disorders.

You ask for some comments on the neurological basis of chiropractic. It is a matter of common knowledge that most tissues and organs are supplied with nerves and that he proper function of these does depend, to a varying degree, on the integrity of these. Thus, for instance, a muscle is quite useless without its nerve supply. On the other hand, the pancreas can probably get along quite well without its nerves, although of course would then be not quite fully functional. There has been a longstanding neurological theory that in some sort of way nerves give the tissues they supply some trophic function. This concept has been never very easy to conclusively prove in scientific terms. A good bit of the so called trophic changes may well be due to disuse than some mysterious trophic or vital function.

While in theory some reduction in the nerve supply to an organ might render it more liable to disease, I know of little work that has ever conclusively proven this, that is apart from those disorders where the disease process is an intrinsic disorder of the nerves itself. The usual sort of thing that happens when nerves are interfered with by pressure or misalignment are pain in the course of the nerve and if the nerve supplies some muscles then there may be some weakness also of these muscles. It has never been very easy to take it any further than that. Thus if the nerves going to your legs were interfered with one might have backache and sciatica, similarly in the arm one might have neckache and neuralgia.[34]

 

There is no doubt that the latter three expert witnesses are specialists in their separate fields. But as we heard them explaining and elaborating our examination of chiropractic we were entering a kind of no man’s land into which medical and scientific knowledge had so far been unable to penetrate with any real success. It is like a French impressionist landscape; outlines are blurred and indeterminate. The objects in the landscape tend to suggest what the patterns might be, but we cannot be certain. We can be hopeful that sooner or later scientists will by stages provide complete answers. But that has not happened yet.

Dr K.E.D. Eyre is a visiting neurologist to the Auckland Hospital Board and is in private consulting neurological practice in Auckland…he did not dispute that a spinal subluxation (in the medical sense) could bring about organic or visceral disorder, and remarked, “We would be wasting our breath to deny otherwise.” In answer to questions on behalf of the Chiropractors’ Association he said (Transcript, pp. 3587-8):

I would readily agree that there are spinal subluxations. I see them every day and I see the effects of them. I am not denying that there is any such things as subluxation or that spinal subluxation produces effects … I would agree that spinal subluxation causes disease. We would be wasting our breath to deny otherwise.[35] (emphasis added)

The Commission appeared more willing to accept this medical evidence at face value and decreed the possibility of the adverse effect of vertebral subluxations upon Type O disorders although it was the first to admit the evidence is scarce.

 As we have already seen, the chiropractic subluxations essentially a biomechanical dysfunction. It is obvious that such a dysfunction can produce back pain. It if can do that, there seems no logical or neurobiological reason why it should not produce other disorders resulting essentially from the original stimulus. But it must necessarily be a matter of speculation: when Dr. Eyre was asked, “Are the interactions between the various systems [of the nervous system]…yet fully understood?” his answer was a positive and immediate disclaimer (Transcript, p. 2073). At all events we take from Dr Eyre’s evidence (Transcript, p. 2062) that vertebral subluxation could cause some alteration of function in the autonomic (or visceral) nervous system and thus alteration of function in the viscera.[36] (emphasis added)

The Commission also took the leap into trophic function of the body by the nervous system when it discussed The Complexity of Homeostasis and the Nervous System.[37] The trophic function is the life-sustaining aspect of the nerve system as differentiated from the sensory or motor functions of the nerve system.

Our bodies are constructed so as automatically to cope with a hostile environment and to resist disease and disorder. It is an automatic compensatory and balancing process. It is known as homeostasis. It not only protects the whole human system from hostile influences: when hostile influences do in fact cause damage it sets to work to repair the damage. So that if we cut our finger the body’s natural healing and recuperative forces are immediately marshaled to put the damage right. It sounds simple. In fact it involves processes and mechanisms complex beyond the imagination of most people. Medical science has certainly not discovered exactly how some of them work. Mechanical and electrical analogies can never provide a complete picture. The human body is much more than just a piece of complicated machinery.

What governs these homeostatic reactions, these processes and mechanisms which are working all the time to ensure our bodies’ normal functioning and which introduce compensatory factors to correct abnormal conditions? No one really knows. What does seem clear is that the processes and mechanisms involved depend on an extremely complex series of responses and interactions in which the nervous system appears to play an important part. When we cut our finger it is probably the nervous system which takes notice of the fact and which marshals and directs the various biochemical agencies to start and carry through the healing process and to guard against infection.

Now as we have said, the working of the nervous system in all it details is not yet fully understood by medical science. But it does seem that science has advanced to a point where it can be said with confidence that a stimulus directed at one point in the nervous system passes through a series of stages and that the final result of the stimulus will depend not only on each of the links between the stages taken separately but also on the state of the whole chain. For this purpose it is a mistake to regard the various branches or departments of the nervous system as anything other than morphologically and functionally interconnected: their exact boundaries cannot be identified. Dr. KED Eyre confirmed this when he told us, in describing its various divisions, that the nervous system had nevertheless to be regarded as “an integrated whole”.

… So if it can be postulated that a spinal dysfunction produces a stimulus in immediately adjacent nerves, that original stimulus may manifest itself in a nervous reaction in another part of the body. Of course, as Dr. Eyre pointed out, the process can work the other way. But take away the original stimulus by correcting the spinal dysfunction and the nervous reaction elsewhere will—or ought to be—reduced, for its cause has gone. That is logical.

… The problem is that in our present state of scientific knowledge no one can really know. A gastric ulcer, for instance, may have developed as a result of abnormal local nerve activity, and that activity may have been induced by nerve irritation at the site of a vertebral joint dysfunction. Or the abnormal activity which has given rise to the ulcer may have resulted from nervous excitation from another source altogether. Dr. Eyre told us that severe burns can produce peptic ulcer. One cannot know for certain. But the chiropractor who identifies a vertebral joint dysfunction could be the cause of nervous irritation activating the ulcer. He adjusts the vertebrae and corrects the dysfunction. If the ulcer is relieved he may reasonably infer that his hypothesis was correct. It is, of course, and necessarily must be, a “wait and see” approach. While the chiropractor’s hypothesis enunciated above could well prove to be scientifically untenable, in the present state of knowledge about the precise working of the nervous system there is no justification for anyone to label the chiropractor’s hypothesis irrational. (emphasis added)

Obviously the Commission was pushing the envelope of scientific knowledge with its train of logic, far beyond anything the medical society had ever done before. The Commission simply connected the dots of scientific logic to conclude that spinal subluxation as joint dysfunction can irritate the nervous system to cause abnormal tissue reaction. It is this leap in logic that chiropractors gladly make but one the medical profession conveniently disavows.

 

Medical Prejudice

Upon review of the testimonies and evidence, the Commission took the controversial position to criticize the medical profession’s own duplicity in regards to the appearance of the scientific stance and concluded they cannot be confident that the medical profession is always the best judge…It was not part of this inquiry to investigate these matters but they are important considerations in the assessment of medical opposition to chiropractic.”

This is a weighty opinion indeed and one to be treated with great respect. For medical practitioners are essentially, by their training and expertise, the guardians of public health. In matters laying within the field of expert medical opinion it is a bold step for anyone not medically qualified to venture to disagree with what they say. But in our view there are three factors which must necessarily seriously diminish the weight to be given to medical opinion on chiropractic theory and practice.

In the first place no evidence was placed before us which suggested that medical science has proved current chiropractic theory to be in error, or the practice ineffective. We have no doubt at all that if such evidence had been available, it would have been produced. It is all very well to assert—as some of the medical witnesses did—that some chiropractic hypotheses are absurd. But if there is no proof that chiropractic hypotheses are unsound, an assertion by a medical expert that the hypotheses are absurd can logically amount to no more than an assertion that the chiropractic hypotheses do not fit into the framework of concepts within which that medical expert is for the time being working. Hypotheses which do not fit into accepted frameworks have often in the past been derided as absurd.

The medical profession branded Pasteur’s hypotheses absurd the theory as to the circulation of the blood was similarly held up to ridicule by the medical profession at the time it was first propounded the history of medicine contains many other such examples. An editorial in the Canadian Medical Journal (85, p. 1056, 1961) puts the position better than we could:

In medicine we have had the dubious privilege of being often wrong. Out greatest sages even, have made blunders which seem, in retrospect, astonishing. Virchow, for instance, the father of pathology, could not be persuaded that deficiency diseases might exist, and this in spite of James Lind’s demonstration that scurvy is prevented and cured by lemon juice more than a century before. Claude Bernard did not grasp the immense importance of bacteriology. Lister’s contemporaries, very able men, were sure that he was either a fraud or a fool, or both. Fleming was considered an amiable crank for years.  So with our knowledge of previous over-certainly we can perhaps be more detached than some disciplines. We have learned to expect, even hope, that time will produce better ideas than we have now.

We therefore cannot be confident that the medical profession is always the best judge of concepts which do not for the time being relate to the pattern of established medical thinking.[38] (emphasis added)

Not only did the Commission accuse the medical society of being intolerant and intransigent to change, but it mentioned evidence that also claimed “medicine is not yet entitled to rank as an exact science”. It is refreshing that this august body of investigators had the courage to confront the medical bias head-on with the given truth that much of medicine is not based on sure scientific knowledgerather than the medical fabrication of its supposed scientific basis. Indeed, the medical critics appear to be the pot calling the kettle black with its accusations calling chiropractic unscientific.

In the words of Bourdillon (Spinal Manipulation, 2nd edition, 1973, pp. 1-2), “only a few generations ago medicine was an art and the large majority of medical and surgical treatments were based on the results of practical experience rather than on firm scientific foundation.” Since then and particularly over the last 40 years major advances have been made, for example in the theoretical understanding of the mode of action of a wide variety of drugs. Fundamental advances in the knowledge of human biochemistry and neurophysiology have placed pharmacology on a much firmer basis… However, it would be ridiculous to claim, and we are sure the medical profession does not do so, that the theories underlying all medical treatment as at present administered are fully understood. These theories are continually evolving, old ones being displaced by new ones as more information becomes available.

Not only that, but the clinical effectiveness of medical or surgical treatment can rarely be exactly predicted. Certainly for many conditions there will be a very high success rate for some treatments but for others there will be considerable uncertainty and the doctor may have to use a “trial and error” approach. So now, as in the past, much of medicine is not based on sure scientific knowledge and medical practitioner cannot predict with certainty the outcome of their treatment. Indeed the words in an editorial in an issue of the British Medical Journal of 1910 (vol.2; 639) apply with nearly the same force today as they did 70 years ago:

It must be admitted that medicine is not yet entitled to rank as a science. It does not fulfill the test of a science—that is to say, the power of prediction. The most experienced among us cannot foretell with absolute certainty the issue even of a trivial ailment, or the action of an ordinary drug in a given case, as an astronomer can predict an eclipse.

Perhaps these words should be modified by stating that “medicine is not yet entitled to rank as an exact science” instead of just “a science”.[39] (emphasis added)

While medicine draws on scientific methods and high-tech tools in its research, rather than admitting much of the practice of medicine is not scientific itself, the medical society chose to ignore this truth and attack the chiropractic profession on the same basis. The Commission called out the medical society for its attack on chiropractic since “No serious research into chiropractic has been undertaken by the medical profession”. Obviously the New Zealand medical association had taken a page out of Morris Fishbein’s book of propaganda and misinformation rather than proving their anti-chiropractic position with scientific proof.

Next, organized medicine sought to justify its position by pointing to the fact that chiropractors had never been able to provide scientific proof of their theories. The burden of proof, it was said, lay on the chiropractors. This is undoubtedly the accepted scientific stance. But is it reasonable to adopt it in the present instance? What are the facts? Chiropractic has been practiced for more than 80 years. During the whole of that time it has been strongly opposed by organized medicine. During the whole of that time chiropractic in spite of that opposition, has consistently gained in public support. During the whole of that time the research resource of established medicine have been immeasurably greater than those of the chiropractic profession during the whole of that time the medical profession has considered chiropractic worthless. No serious research into chiropractic has been undertaken by the medical profession. There are, indeed, considerable problems in conducting controlled clinical trials: as we shall see it is difficult research area and requires full-time trained personnel: it cannot be undertaken successfully by busy practitioners.

We agree that chiropractic have paid insufficient attention to recording their clinical experience. But they have been kept outside the scientific community, and their facilities have been limited.

The argument that the burden of proof should be placed on the chiropractors is an attractive one, but in the circumstances we find it evades the real issue. The belief central to chiropractic is that a mechanical vertebral dysfunction can, through some neurological mechanism, not only cause local pain but also influence visceral function. Current neurophysiological knowledge is simply inadequate to subject this belief to thorough scientific scrutiny, and chiropractors cannot be held responsible for these shortcomings certainly on present knowledge, their theory cannot be ruled out.

The third factor which in our view diminishes the weight of the general objection of organized medicine to chiropractic is the degree of ignorance of chiropractic which seems to us to pervade much of the medical comment on it…we think it clear, on all the evidence put before us in this most comprehensive inquiry, that the educational background of the present day medical practitioner does not equip him to evaluate the refinements of a chiropractor’s skill in diagnosis and treatment of spinal dysfunction of biomechanical origin. Unless chiropractic is studied on its own terms no more than an indistinct image emerges. It is like trying to get a good television reception without a correctly oriented aerial.

For any of those reasons then, it is impossible for us to treat the evidence called on behalf of the New Zealand Medial Association as in any way conclusive. It is certainly entitled to weight; but it is to be regarded as no more than evidence of weight among other evidence.[40] (emphasis added)

 

Recall that initially the Medical Association suggested that the theory of chiropractic is “absurd,” but when the Commission rejected that assumption, then the Medical Association resorted to its “underlying bias” that “certainly went beyond skepticism” when the Medical Association suggested the benefits of chiropractic are largely “illusory” and “placebo” (Submission 26, p 125).

“…there is little or no evidence to suggest that the benefit of chiropractic care is in any way due to the mechanical effects of manipulation; on the contrary, there is good evidence to suggest that the benefit stems from the transference of confidence from chiropractor to patient, the sharing in faith in manipulation as a form of therapy, the placebo effect of the laying-on of hands, and the fact that the minor musculoskeletal disorders which are the backbone of chiropractic are themselves self-limiting or subject to spontaneous remission.” (emphasis added)

 

Indeed, the Commission summarized its position when it stated “Chiropractic cannot be fairly evaluated from a library desk”[41] nor from the misinformation from Morris Fishbein’s brand of political medicine.

The Commission regards this as a persuasive but facile attempt to explain away the results achieved by chiropractors, some physiotherapists, and some doctors who specialize in manual therapy. The Commission accepts that in some cases some of the factors mentioned by the Medical Association may assist the practitioner in achieving the result. But on the whole of the evidence we reject the Medical Association’s submission as a complete explanation of chiropractic successes.[42]

In our evaluation of the Medical Association’s principal submission we must not overlook what we see as the general medical attitude towards chiropractic. It was clearly identified for us not only by the writer of the principal submission but by other medical witnesses as well. It is an underlying bias against the health practitioner who does not have an orthodox medical qualification; an unwillingness to admit even the possibility that in the specialized are of spinal manual therapy chiropractors are better trained than any ordinary medical practitioner and more skillful in that art than most medical practitioners.

Now it is right that organized medicine should be skeptical of the claims of unqualified practitioners. It is the public interest that organized medicine should have that attitude. Doctors have a professional responsibility to warn and if necessary to defend the community against any health treatment which for one reason or another could be hazardous or which is ineffective.

So medical skepticism has its place. And chiropractors have only themselves to blame if that skepticism is increased in their case by more extreme chiropractic literature and the unwise activities of a few chiropractors. But, as we have said, the principal submission of the Medical Association certainly went beyond skepticism. We are satisfied that organized medicine in this country has never given chiropractic a fair trial.[43]

There is, however, one point which we wish to mention particularly. In this report we have been obliged to direct some criticism at organized medicine in New Zealand. Its opposition to chiropractic is, in our finding, largely misconceived.[44] In our opinion the medical “political” attitude to chiropractors, which some doctors and others have tended to accept uncritically, is based on misinformation and ignorance. We are satisfied that some ordinary general practitioners already recognize the benefits of spinal manual therapy. They have seen for themselves what chiropractors can accomplish, and regard those chiropractors as skilled practitioners in the art.[45] (emphasis added)

The Chiropractor’s Dilemma

The Commission was very insightful of the impact the medical prejudice and social ostracism born upon chiropractors. Just as any prejudice hurts the self-image of its victims, so too has medical bias created a unique psychological outlook by chiropractors. It also commented on the safety and improved quality of life of chiropractic care.

All in all, New Zealand chiropractors, as we have observed them, bear the stamp of their calling. They have a seriousness of purpose and a stability that invite comparison with the medical profession. Yet the latter officially still hang the charlatan label on them. This makes chiropractors resentful and causes them to feel threatened. New Zealand chiropractors do not see themselves just as “fixers of backs”, but neither do they see themselves as cult figures with magic powers… They present themselves as skilled practitioners, working mainly in a well-defined area… We should then all see chiropractors as they should be seen, as partners, not outsiders.[46]

Tens of thousands of patients have gone through chiropractors’ hands in this country. They have apparently suffered no ill effects. We have no doubt that every effort was made to locate verifiable cases of harm caused by chiropractors. The conspicuous lack of evidence that chiropractors cause harm or allow harm to occur through neglect of medical referral can be taken to mean only one thing: that chiropractors have on the whole an impressive safety record.[47]

The Commission is satisfied that although the chiropractor may not cure life-threatening diseases, he certainly improves the daily lot of many people. Without him, the equality of life of many would be less bearable. Their pain and frustration are undoubtedly relieved. There is no gainsaying that.[48]

Chiropractors cannot hold themselves out as providing a separate, distinct, and comprehensive system of health care. (p. 251) … The commission does, however, have strong reservations about some aspects of modern chiropractic… among other things discipline within the chiropractic profession is unsatisfactory.[49]

The true—as distinct from the imagined—obstacles to the incorporation of chiropractors into the health team are, first, the medical establishment’s refusal to accept them, and secondly the unprofessional activities and claims of some chiropractors. It is clear that the chiropractors must act decisively to impose proper ethical and professional standards on those guilty of unacceptable conduct, and we suggest means by which they should be helped to do this. Once the few maverick chiropractors have been brought under control, there can be no rational ground for any medical opposition to the inclusion of the chiropractic profession in the general health team.[50]

The Commission also noted the quandary placed upon ethical MDs who referred to chiropractors and the fact that patients are the ones who also suffer from this medical bias.

A medical practitioner who discusses a patient’s condition with a chiropractor therefore runs a grave risk, and any suggestion of their working in harness in regard to a particular patient is in general, in the present situation, out of the question. The Commission cannot avoid seeing this as an attempt by organized medicine to cut off the patient’s nose to spite the chiropractor’s face [51] (emphasis added)

Chiropractic As A Last Resort

As is often the case the USA, the NZ investigators also found that many patients used chiropractic care after failed medical care whether due to their own skepticism or due to the refusal of MDs to refer cases to chiropractors.

It appeared from the questionnaires and letters that a very large proportion of respondents had gone to a chiropractor only after medical treatment or physiotherapy had failed them. Indeed that was a message that came to us very clearly through our inquiry. Those patients at least appeared to be satisfied that he chiropractor was able to put them back on their feet more quickly and more effectively than any other practitioner.[52]

The great majority of patients who responded believed that they had obtained significant relief from chiropractic treatment. Most of them were treated for Type M disorders, but a proportion (7 percent) believe they had obtained at least a degree of relief in Type O ailments.[53]

We do not say that medical health benefits should be withheld from patients unless the treatment can be guaranteed to be successful (or is demonstrated subsequently to have been successful) and the basis for its success is scientifically established that being so, we feel it is unreasonable to oppose benefits for chiropractic treatment on those grounds.[54] (emphasis added)

On Top Down Under

As you can see, this two-year inquiry in New Zealand was important on many levels. First, it was the only governmental agency to investigate the chiropractic profession in an even-handed manner without the usual medical meddling as we saw in the USA with the AMA’s interfering with Medicare. It would be another fifteen years before the US Public Health Service released its AHCPR guideline on acute low back pain in 1994, but then we also watched as the NASS killed this agency.

Secondly, the Commission looked into the scientific aspects of chiropractic that were, in effect, on the leading edge of science. Despite the lack of research into the underlying mechanism of chiropractic care, the Commission did not throw the baby out with the bathwater when the evidence appeared thin and speculative. The fact that there is not yet any conclusive explanation of exactly what happens means nothing more than that the chiropractors’ hypothesis is so far unproven. It does not mean it is invalid.”[55]

Thirdly, the Commission delved into the social-psychology of chiropractors to see the impact of the medical assault has taken upon them. The Commission admitted the good work of chiropractors and realized the negativity from the Medical Association with its epithets and branding of all chiropractors as charlatans. We are satisfied that organized medicine in this country has never given chiropractic a fair trial.”[56]

Fourthly, the Commission was painfully honest in its criticism of political medicine to boycott chiropractic as quackery and it was just as honest to call out the few mavericks in chiropractic who made outlandish claims in spurious advertisements. first, the medical establishment’s refusal to accept them, and secondly the unprofessional activities and claims of some chiropractors.” [57]

Fifthly, the Commission showed a remarkable talent to analyze the complex arena of the medical war and offer constructive suggestions. The insight provided by the Commission exceeded a mere analysis of the existing facts; indeed, these investigators seemed willing to make conclusions that would have been attacked if not for their even-handed analysis. Certainly the impact upon patients was not lost when it stated: “The Commission cannot avoid seeing this as an attempt by organized medicine to cut off the patient’s nose to spite the chiropractor’s face …”[58]

Indeed, the NZ Commission did an admirable job to pull together many loose ends in the medical war and came to honest answers and suggestions. It is regrettable this information has gathered dust in the archives rather than applied to the present situation that has gone relatively unchanged over the last thirty years.



[1] Inglis, BD, Fraser, B, Penfold, BR, Chiropractic in New Zealand, Report of the Commission of Inquiry into Chiropractic,  PD Hasselberg, Government Printer, Wellington, New Zealand. 1979, 43-44

[2] Inglis, ibid. p55.

[3] Dew, Kevin. “Apostasy to orthodoxy: debates before a Commission of Inquiry into chiropractic.” Sociology of Health & Illness, vol. 22, no.3, 2000, pp. 314-15.

[4] Ibid. p. 1.

[5] Ibid. p.1.

[6] Ibid. p. 119

[7] Ibid. p. 201

[8] Ibid, p. 28.

[9] Ibid. p. 42.

[10] Ibid. p. 3

[11]   Ibid. p. 40

[12] Ibid, p. 194.

[13] Ibid. p. 52.

[14] Ibid. p. 49

[15] Ibid. p. 50.

[16] Ibid. p. 51.

[17] Ibid. p. 55.

[18] Ibid. pp. 49-55.

[19] Ibid. p. 158

[20] Ibid. p. 176

[21] Ibid. p. 43

[22] Ibid. p. 216

[23] Ibid, pp. 216-7

[24] Ibid. pp. 43-44

[25] Ibid. p. 47-8.

[26] Ibid. p. 244

[27] Ibid. pp. 57-8

[28] Ibid. p. 218.

[29] Ibid. p. 220

[30] Ibid. p. 218.

[31] Ibid. p. 219

[32] Ibid. p. 219

[33] Ibid. p. 219

[34] Ibid. pp. 101-2                                                                                           

[35] Ibid. p. 136

[36] Ibid. p. 137

[37] Ibid. pp. 134-5

[38] Ibid. p. 120

 

[39] Ibid. pp. 220-1.

[40] Ibid. pp. 119-21

[41] Ibid. p. 128

[42] Ibid. p. 127

[43] Ibid. p. 128

[44] Ibid. p. 2

[45] Ibid. p. 252

 

[46] Ibid. p. 97

[47] Ibid. p. 78

[48] Ibid. p. 199

[49] Ibid. p. 2

[50] Ibid. p.253

[51] Ibid. p. 64.

[52] Ibid. p. 150

[53] Ibid. p. 150

[54] Ibid. pp.220-1

[55] Ibid. pp. 49-55.

[56] Ibid. p. 128

[57] Ibid. p.253

[58] Ibid. p. 64.

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