We Get Letters

The Somato/Visceral Hypothesis -- a Gray Area

Dear RHT:

I would like to make an observation and a few comments regarding your recent article "Fearless Chiropractic." Normally I enjoy reading your column as I think you have some interesting perspectives on chiropractic which I can appreciate and respect regardless of whether I agree with you or not. Many times I do agree with your basic premise although I would be hard-pressed to classify some of your positions as middle ground.

Unfortunately, in the article I refer to above I think you are really doing the profession a disservice by suggesting that the somato/visceral hypothesis cannot be proved or, worse yet, that researchers will be throwing up their hands in horror shouting it can't be proved. Further, you state that the middle ground chiropractors possess the least amount of professional courage. Sadly this is just the "out" many chiropractors will look for to continue to devotedly follow like sheep the basic chiropractic philosophical tenets (bone on nerve, compressed hose, organ dysfunction) without critically evaluating these ideas within the context of our current state of knowledge.

Referring to the statement regarding proof of the somato/visceral hypothesis, you've really demonstrated your ignorance of basic research principles which, by the way, is shared by an alarming number of chiropractors in our profession despite the best efforts of people like Keating, Meeker, Jansen, ad infinitum. The term "proof" is a relative term when used in the research context. Any scientist will tell you that absolute proof of anything is quite impossible. Forget scientists, I learned this is my seventh grade science class. While I didn't know then why this was true (and I'm not sure my teacher did either) the answer can be found by anyone, in the quantum mechanics chapter of any decent physics text. It turns out that any statement made regarding any physical phenomena in our universe must be a statement of probability (the Schrodinger Equation), and furthermore that the act of observation of the physical world introduces an inevitable uncertainty as to what you saw (the Heisenberg Uncertainty Principle).

Having said this, it is apparent that research is not meant to provide absolute proof for anything. What it will do is lend support to or tend to refute our hypothesis, thus improving our "probability statements" regarding our ideas. When the right questions are asked, the somato/visceral hypothesis is eminently testable and "probable" to the extent that science allows us to do so. To suggest differently allows for the continuing use of ethereal philosophical terms such as innate to be used as a rationale and explanation for which chiropractic "works"; our profession deserves a much greater fate than relegation to a pseudoscientific cult.

With regard to professional courage, you say that the middle ground chiropractors seem to have the least, therefore implying that the extremists have the most. Quite the contrary -- I can think of nothing less courageous than accepting only those ideas which support your point of view, or that came down from the teachings of the chiropractic deities. For the extremists, things are black and white. One group refuses to critically evaluate any of the chiropracTIC religion they learned in school or practice management sermons (silly me, I mean seminars). The other group critically evaluates all information using only a strict medical model, which is flawed at best. Both groups are dogmatic with their belief.

Real professional courage is being demonstrated by those chiropractors who continually live in the gray area of clinical practice, constantly reassessing their current ideas and practices, and taking the time and effort to critically evaluate incoming information. Let's face it, there are a lot of gray areas when dealing with the human body. Like it or not the somato/visceral reflex hypothesis lies firmly in that gray area given our current state of knowledge.

As practicing clinicians, we must always strike a balance between our current state of research knowledge and our empirical knowledge gained from our experience. You have been influenced by your empirical findings to accept the somato/visceral hypothesis as an operating principle in your practice, but unfortunately empiricism is not directly transferable from person to person and hardly useful in any manner when communicated anecdotally. If you really wanted to draw up support for the hypothesis, your efforts would have much more utility by writing and submitting case studies (or better yet single case time series designs) for the patients you mention.

As for me, the hypothesis continues to be firmly planted in the gray area -- some of my experiences have supported it while others have not. To suggest that my decision to focus my practice (for the time being) on primarily neuromusculoskeletal problems is based on me wanting to be a medic, and is a disservice to me and all the doctors out there who have made that conscious decision. You have to believe in what you are doing. I hope nobody alters their current practice philosophy because someone as visible as you implies they're not courageous if they don't start claiming to treat cardiac arrhythmias.

I grow tired of people who forever claim they support research and accept it as a vital part of our professional growth, but then only really do so if they think the research will be able to support what they currently do. You need to ask yourself what would happen if our researchers developed a large body of evidence which tended to refute the idea of the chiropractic adjustment positively influencing organic function. Are you courageous enough to accept this finding and modify your clinical management of patients accordingly? You don't get to pick and choose what you like out of our body of research knowledge because it happens to fit with your current paradigm, else paradigms would forever remain unchanged and you would be guilty of committing the same offense you so vehemently charge the MDs are guilty of with regard to accepting alternate ideas that don't fit their model.

I find it intriguing that the same chiropractors who all along have seen research as an evil thing -- that will never be able to "prove" our theories because it's really an extension of the poisoned medical profession and therefore can't possibly detect what innate and the holy adjustment does to our bodies -- have been first in line to trumpet the results of the BMJ study as irrefutable truth that chiropractic works. How many of these chiropractors will even consider for a moment modifying their cookbook treatment schedules despite the suggestion that these long-term positive results were gained with 12 adjustments or less? (It is possible that it doesn't take exactly 113 adjustments after all?) How many of these same chiropractors who have run full-page newspaper ads with the study abstract and conclusions would have ever heard of the study if it had suggested that the physical therapy gave superior results? I'll bet very few. If they did hear or read about it, how many would have disregarded the conclusions because of the poisoned research theory or any one of dozens of other popular rationalization? Too many, I'm afraid. I'm not implying that you are necessarily one of those chiropractors, but you provide them with yet another rationalization to discard data that's not chiropracTICly pleasing.

Nobody is suggesting that everything we currently do or say must be supported by a controlled clinical trial, or even that we have to agree with all of the results that come about through research -- long live the critical peer review process. But don't imply that those of us who haven't "seen the light" with respect to the somato/visceral hypothesis are either "wanna-be" medics or somehow less courageous.

You see, your "anatomy and natural physiological assumption" is a rationalization by any other name. I'm quite sure that early physicians who drilled holes into their patients' heads to let the evil spirits out based this practice on the "natural physiological assumption" of the day.

Brian E. Wirick, D.C., C.C.S.P.
Sonoma, California

Dear Editor:

The motivation for writing this letter is the disappointment I felt after reading Dr. Michael S. Horney's article "The Way It Should Be -- A Case Study," in the August 2, 1991 issue of Dynamic Chiropractic.

I agree that we must keep the patient's best interest at heart. We must provide the best chiropractic care we're able to deliver. Unfortunately, some cases will not adequately respond and a prompt referral is warranted.

While I was glad to see Dr. Horney refer Mrs. V to a neurologist, I was disappointed it took approximately 100 office visits to decide she was not responding to chiropractic's conservative approach. The article stated that among other clinical findings, the initial examination revealed a left "O" ankle reflex and a positive left straight leg raising test. In addition, radiographs and MRI studies confirmed a large herniated nucleus pulposus (HNP) L5-S1, and degenerative disc disease.

With this information at hand, I just don't understand why it took 5 months and approximately 100 office visits to refer. Is this "The Way It Should Be?"

George T. Foedisch, D.C.
Lansdale, Pennsylvania

Dear Editor:

In your August 2, 1991 issue of Dynamic Chiropractic, two very important subjects were addressed by Dr. Michael S. Horney and Dr. Frances Wiggins.

If every chiropractor in the world practiced with "the patient's best interest" in mind, as was pointed out by Drs. Horney and Wiggins, we would not have a public relations problem with the general public, medical community or any community for that matter.

Perhaps having a world filled with honest health care practitioners is just wishful thinking.

I commend Drs. Horney and Wiggins for sending us all a little wake-up call.

Dale J. Buchberger, D.C.
South River, New Jersey

Dear Editor:

To firmly make the imprint, the chiropractic profession is needed as a distinct and separate healing art. Through correction of vertebral subluxation, we allow the body to correct that which is in need of correction.

I take particular exception to the view point of Dynamic Chiropractic in seeming to deem the chiropractic adjustment as merely an insignificant part of chiropractic. The philosophy becoming unneeded or unwanted would seem to be its goal.

The legislative niche that chiropractic has carved for itself is separate and distinct. No other profession offers the removal of nerve interference by correction of the vertebral subluxation. There are, of course, other aspects of doctoring, and it certainly was not modality practice. This arena was delegated to the eclectic physician.

Tread softly my senior colleagues. (By) ridding ourselves of the philosophy, chiropractic is relinquishing its uniqueness and possibly its future. Do not give up the uniqueness for acceptance. Political victories and legislative footholds are indeed fruitful to our profession. But, do not give away the fundamental principles of our profession in order to gain acceptance.

"It is because we have lost our focus that so many use hocus-pocus."

-- Fred H. Barge, D.C., Ph.C.

We, as a profession, have so much more to offer than merely being delegated to a musculoskeletal level. We have to offer a new philosophy in health, which is the principle of life.

George Kosmides, Intern
Pico Rivera, California

Dear Editor:

We are indebted to Dr. Willard Bertrand for his article "Above -- Down." The philosophical basis for the chiropractic profession was so wonderfully described in his article and was such a refreshing change after reading the recent National College of Chiropractic (NCC) publication on chiropractic philosophy.

We should be able to lift ourselves above the bickering over semantics and realize that "innate intelligence" are simply two words used to describe the ability of the body to correct itself. I personally believe "innate intelligence" is a very appropriate way to describe this principle, but if some find it "unscientific," then, by all means, choose some other words.

No matter what words you use to describe it, the fact is the body does have a built-in tendency to correct itself. The fact is that we, as a profession, recognize this and work to enhance that tendency rather than work in opposition to it. This is what gives us a philosophy quite separate and distinct from medicine. To lose that would relegate us to the level of physical therapists.

Kenneth Law-Davis, D.C.
Pittsford, New York