The early years of organized chiropractic orthopedics, 1954-1973: a social history.
Abstract: Objective: This paper presents the origins and development of the organized chiropractic orthopedics movement in the United States from 1954-1973.

Methods: Hand searches of early periodicals were performed and information was organized chronologically to create a timeline. Context for the timeline was provided by extracting pertinent information from audio recordings of interviews. Relevant background information was located using the cumulative index of the journal Chiropractic History and searching the MANTIS database.

Historical Features: After World War I, The advent of third party reimbursement for health care created a new environment for health care practitioners. For doctors of chiropractic, this event provided the impetus to begin the postgraduate chiropractic orthopedics program over 50 years ago. In 1954, Alvin A. Hancock, DC and F. Maynard Lipe, DC successfully launched an active orthopedics movement after several earlier attempts failed during the 1940s and early 1950s. The movement generated from the desire to train and certify chiropractors to manage personal injury and workers' compensation low back injuries. In addition to developing interdisciplinary educational programs, the chiropractic orthopedics group was responsible for producing a research agenda, some of the profession's early orthopedic-focused research, and for starting the National Council on Chiropractic Orthopedics of the National Chiropractic Association, which later became the American Chiropractic Association Council on Orthopedics. These organizations produced thousands of specialists in chiropractic orthopedics, later known as Diplomates of the American Board of Chiropractic Orthopedists.

Conclusion: Several orthopedics interest groups were formed and credentialing processes were created to qualify doctors as recognized chiropractic orthopedics specialists. The popularity of this movement resulted in the inclusion of orthopedics into core chiropractic college curricula and the production of various research studies before the development of the modern science of chiropractic. (JCCA 2009; 53(2):129-143)

KEY WORDS: chiropractic; orthopedics; education, continuing; history of medicine; research

Objectif: Le present article presente les origines et Vevolution de l'organisation du mouvement d'orthopedie chiropratique aux Etats-Unis, de 1954 a 1973.

Methodologie: On a procede a une recherche manuelle des magazines de la premiere epoque et de l'information, qui a ete structuree par ordre chronologique pour creer un historique. La mise en contexte a ete faite a partir d'extraits de renseignements pertinents, notamment d'enregistrements audio d'entrevues. Des donnees historiques pertinentes ont ete reperees en ayant recours a un index cumulatif de la revue Chiropractic History et en faisant une recherche dans la base de donnees MANTIS.

Caracteristiques historiques: Apres la Premiere Guerre mondiale, la mise en place d'un remboursement par un tiers des soins de sante a cree un nouvel environnement pour les praticiens. Pour les medecins de la chiropratique, cette conjoncture leur a donne l'impulsion pour commencer un programme d'etudes superieures en orthopedie chiropratique, il y a 50 ans. En 1954, Alvin A. Hancock, docteur en chiropratique et F. Maynard Lipe, docteur en chiropratique, ont lance avec succes un mouvement dynamique d'orthopedique apres plusieurs tentatives malheureuses dans les annees 1940 et 1950. Le mouvement etait issu du desir de former et d'agreer des chiropraticiens capables de traiter des lesions corporelles et des douleurs au bas du dos, dans le cadre de l'indemnisation des accidentes du travail. En plus d'elaborer des programmes educatifs interdisciplinaires, le groupe d'orthopedie chiropratique a ete responsable de produire un agenda de recherche, d'effectuer les premieres recherches centrees sur l'orthopedie et de lancer le conseil national des orthopedistes chiropratiques (National Council on Chiropractic Orthopedics) au sein de la National Chiropractic Association, qui est devenu par la suite l'American Chiropractic Association Council on Orthopedics. Ces organisations ont forme des milliers de specialistes, appeles plus tard les diplomates du American Board of Chiropractic Orthopedists.

Conclusion: Plusieurs groupes d'interet a l'orthopedie ont ete formes et des processus d'agrement ont ete institues pour remplir les conditions pour devenir medecins reconnus comme specialistes de l'orthopedie chiropratique. La popularite de ce mouvement s'est traduite par l'inclusion de l'orthopedie comme specialite centrale dans les programmes de chiropratique et la production de diverses etudes avant l'arrivee de la science moderne de la chiropratique. (JACC 2009; 53(2):129-143)

MOTS CLES: chiropratique; orthopedie; education, continue; histoire de la medecine; recherche
Subject: Chiropractors (Training)
Chiropractors (Services)
Medical education (Usage)
Authors: Green, Bart N.
Johnson, Claire D.
Pub Date: 04/01/2009
Publication: Name: Journal of the Canadian Chiropractic Association Publisher: Canadian Chiropractic Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Canadian Chiropractic Association ISSN: 0008-3194
Issue: Date: April, 2009 Source Volume: 53 Source Issue: 2
Topic: Event Code: 280 Personnel administration; 360 Services information
Product: Product Code: 8041000 Chiropractors NAICS Code: 62131 Offices of Chiropractors SIC Code: 8041 Offices and clinics of chiropractors
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 259590204
Full Text: Introduction

Today, orthopedics, traditionally a medical specialty, is a recognized specialty in the chiropractic profession. Chiropractic orthopedists are known as doctors of chiropractic who have advanced training in the diagnosis and conservative management of musculoskeletal injuries. Since 1972, the organization responsible for overseeing educational programs and examination of orthopedic specialists is the American Board of Chiropractic Orthopedists (ABCO). (1) Once a chiropractor completes postgraduate specialty training and passes certifying examinations, he or she is designated as a Diplomate of the ABCO. Since the ABCO's inception, more than 1200 chiropractors have been registered as Diplomates (communication with the ABCO Executive Director, Paul Smith, August 20, 2008).

The ABCO defines chiropractic orthopedics on its website (http://www.abconet.org) as the following: ... the branch of chiropractic medicine that includes the continued acquisition of knowledge relative to both normal functions and diseases of the body as they relate to the bones, joints, capsules, discs, muscles, ligaments, tendons, their complete neurological components, referred organ systems and contiguous tissues; AND the development and perfection of skills relative to health maintenance when such exists and when not, the historical review, physical detection, correlative diagnosis development and complete management of any disorder within the bounds defined herein; AND the delivery of the combined knowledge and skill on a primary basis to patients who both need and desire this service to eventual outcome of remission, whenever resolution is not readily available.

Despite the popularity of this specialty, details of its origins are not published. This study investigates how and why this specialty began, how definitions of chiropractic orthopedics changed over time, and describes the people who were dedicated to advancing this movement. Using both qualitative and quantitative methods, this report traces the development of the chiropractic orthopedics movement from its beginning, in the early 1950s, to the 1970s when the credentialing process began.

Methods

In this mixed-methods study, historical data were extracted primarily through hand searches of the publications listed in Table 1. For these searches, each issue of these publications was searched page-by-page to locate data relevant to the chiropractic orthopedics movement. This information was organized chronologically to create a timeline, which served as the basis for this paper, prepared using a previously published historical reporting format. (2)

Qualitative data were primarily collected from interviews. Context for the timeline and motivating factors for early proponents of chiropractic orthopedics were provided by extracting pertinent information from audio recordings of interviews conducted with people involved in establishing the orthopedics movement. Further, articles providing additional context and relevant background information were located using the cumulative index (1981-1999) of the journal Chiropractic History, and a search of the MANTIS database using the search terms 'chiropractic,' 'orthopedics,' and 'research.'

Historical Report

Initiating Factors

In 1938, the introduction of the National Chiropractic Association's (NCA) Committee on Educational Standards (3) set in motion the factors and environment that would stimulate an orthopedics specialty movement. The NCA Committee, through the efforts of its Director, John J. Nugent, DC, sought to amalgamate and reform the many for-profit chiropractic institutions of the period by transforming them into fewer, professionally owned, nonprofit schools in order to improve educational standards. (4) A result of this reformation was curricular changes that removed specialty topics, such as obstetrics, psychiatry, and proctology, from the fundamental chiropractic education curriculum, thus, paving the way for these topics to be included in postgraduate educational programs.

One of the early actions of the NCA Committee was the amalgamation of chiropractic colleges in Southern California. Through this effort, the Los Angeles College of Chiropractic (LACC) merged with the Southern California College of Chiropractic in 1947. Retaining the LACC name, the college became a non-profit institution. (5) In keeping with the merger policies of the California Department of Education, the core curriculum was changed on September 8, 1947 to provide greater inclusion of basic topics in chiropractic education that lead up to a Doctor of Chiropractic degree. (6) Ralph J. Martin, DC, then the president of the LACC, reported to the profession changes that it could expect to see in the educational process. (7)

As a first step to provide education to field doctors in specialty topics that had been reduced or eliminated from the core curriculum, (7,8,9,10,11) the college offered post-graduate classes in obstetrics and gynecology, dissection, spinographic interpretation, physiotherapeutic modalities, malpractice, and jurisprudence through its newly formed Graduate School. (12) Thus, orthopedics was not the first postgraduate chiropractic specialty program for LACC; the first long-term LACC Graduate School course offered was in roentgenology, which started on January 31, 1948. (9) At the time that the LACC Graduate School formed, the California Educational and Specialty Societies were formed to produce and monitor chiropractic post-graduate programs. The Specialty Societies were governed by the California Chiropractic Association (CCA), the NCA and the California Chiropractic Educational Foundation, which was the governing body of the LACC. (13,14,15)

With the Graduate School in place, two separate groups of chiropractors, each unaware of the other's aspirations, competed to create an orthopedics course to be delivered through the Graduate School since there was no orthopedics course in the core curriculum at that time. One group was comprised of Joseph Berg, Fred Nuss, Elmer Bones, and George Bodel. The other group included Everett Hollenbeck, M.L. Miller and Alvin A. Hancock. (16) Nuss et al's proposal was selected and the course started in 1948, but it stimulated little interest from doctors in the field. (14) At that same time (September 1948), a one-year evening post-graduate course at the LACC was approved by the State Department of Education, which included classes in orthopedics and other topics. (18,19) No further mention of this course was found, so it is assumed that it never came to fruition. Many other unsuccessful attempts to provide the minimal enrollment necessary to hold post-graduate orthopedics classes occurred through 1953. (20,21,22,23,24) While a system was in place to start a program in chiropractic orthopedics, including a graduate school and a regulating body, it was not until the middle of 1954 that a post-graduate course in orthopedics was able to thrive. This was the beginning of the chiropractic orthopedics movement.

The Beginnings--A California Phenomenon

One of the primary protagonists of the orthopedics movement, Alvin Hancock, DC, has recorded that organized chiropractic orthopedics began as the result of an enticing speech that decried the high costs and poor outcomes of surgical care for intervertebral disc injuries. At a CCA seminar held on March 10, 1954, Frank B. Hamilton, DC, ND, a LACC faculty member, proclaimed that the chiro practic profession could not only help with the problem of treating low back injuries in a conservative manner, but profit from it. In his speech, titled "Dollars from Sense" he said, (16) "If you chiropractors could come up with a conservative treatment for disc injuries, which is reasonably effective, the insurance companies would gladly pay one thousand dollars per case." Thus, the incentive was declared. It can only be speculated to what degree Hamilton's claim of 1000 US dollars per case (in 1954 currency) served as an incentive. The same $1000 claim would be worth approximately $8100 USD per case in the year 2008 (calculated using inflation calculator from: http://www. bls.gov/data/inflation_calculator.htm).

At this time the sacro-occipital technique program of Major Bertrand DeJarnette, DO, DC was popular with chiropractors, (25) and several doctors involved in this technique system were present for Hamilton's speech. These doctors, who used sacro-occipital technique to help patients with disc injuries, began, "... discussions among themselves as to the best way to try to sell their services to the insurance companies." (16) These discussions eventually led to the conclusion that a specialty society should be formed to construct a curriculum that would include the use of, "... recognized diagnostic procedures used to differentiate various spinal pathologies, including disc injuries and the terminology necessary to report such findings." (16) Alvin A. Hancock, DC, a private practitioner from San Bernardino, California (Fig 1), became the leader of the group and submitted a new petition to the LACC and the California Educational and Specialties Society in 1954 to form a specialty society in chiropractic orthopedics. (16,26) Hancock was a logical choice for spearheading a new movement in California. Hancock was very familiar with political structures and community in the state; he was a founding member of the CCA and a member of its Board of Directors. (27) He also held numerous positions on CCA committees and other organizations related to the CCA and NCA. (28,29,30,31,32) Thus he had the skills, knowledge, and professional network to successfully implement a specialty group.

Hancock's new request to the LACC for a post-graduate orthopedics course prompted the inclusion of "nonsurgical orthopedics" on a survey that was disseminated to the profession in the college's professional publication, the Chirogram in August 1954. (33) The purpose of the survey was to determine the level of interest that chiro practors possessed in various potential post-graduate programs. Late in that same year, Hancock wrote to Dr. George Taylor, Chairman of the CCA House of Delegates, about the need for a chiropractic orthopedics specialty society. Hancock assured Taylor of adequate interest to maintain the society and asked for help to undertake the project. Taylor provided advice for bylaws, a curriculum, instructors, and the experiences of other societies. A tentative curriculum and bylaws for the new society were presented to the House of Delegates.

[FIGURE 1 OMITTED]

The House of Delegates approved the application to form a Division of Chiropractic Orthopedy under the General Practice Society (Fig 2) on December 9, 1954.16

The orthopedics society's post-graduate curriculum proposal consisted of an interdisciplinary faculty including chiropractors, medical doctors, osteopaths, and attorneys. The curriculum required double the amount of training, boasting 216 hours for completion, compared to the 108 hour post-graduate courses that were offered in roentgenology, obstetrics, and general practice at the time. The orthopedic curriculum consisted of the topics listed in Table 2. (16)

The new society began immediately. On January 15, 1955 the CCA House of Delegates, the LACC and the California Educational and Specialties Society approved the bylaws and new curriculum. The first society elected its initial panel of officers including E.C. Hollenbeck as president, Alvin A. Hancock as vice-president, M.L. Miller as secretary-treasurer, and Ordean A. Syverson as a delegate to the CCA Specialty Societies House of Delegates. (16) Twenty-five doctors attended the first approved class in chiropractic orthopedics on April 16, 1955. The course instructor for the next two years was Ronald M. Lawrence, DO, who was assisted by a panel of well-known guest faculty (Fig 3).

F. Maynard Lipe, DC (Fig 4), a 1933 graduate of the National College of Chiropractic, (34) began attending the course in May 1955 and "... took an active role in shaping the destiny of chiropractic orthopedics." (16) He was elected president of the society in its second year. (16,35) The first two years were undeniably productive for the new society. Ordean Syverson published articles about whiplash in the Chirogram (36) and the Journal of the NCA, (16) and Lipe wrote an article regarding the importance of patient referrals to chiropractic specialists, published in the Chirogram. (37) Meanwhile, Dr. John Creighton created and reviewed several orthopedic clinical examination forms to be used by members of the society. (16) In an article published in the Chirogram in 1956, Lipe reported that the course would continue in 1957 and urged doctors to attend: (38)

[FIGURE 2 OMITTED]

At this time William A. Watkinson, DC (Fig 5), the past president of the NCA, related the purpose of the orthopedic society to Frank Hamilton's initial speech. He said, (26) "Graduates of the course found themselves more qualified to examine, treat, and report on insurance patients."

For the first three years of its existence, the orthopedic group was a subdivision of the General Practice Society of the California Chiropractic Educational and Specialty Societies. At this time, president Lipe was able to obtain recognition from the California Chiropractic Education and Specialties Societies for the group to become independent from the General Practice Society. Thus, the California Society of Chiropractic Orthopedists (CSCO) (Fig 2) was born in 1957.39

[FIGURE 4 OMITTED]

Full recognition by the California Chiropractic Education and Specialty Societies involved more responsibilities for the CSCO and its members. To be a society meant that the members must be recognized as possessing additional qualifications beyond those of the Doctor of Chiropractic degree. To fulfill this requirement, the first qualifying examination was administered on June 16, 1957. Officers for the new society were also needed, and elections were held immediately following the grading of the qualifying examination. More tasks followed when the LACC asked the CSCO to provide its own instructors for the orthopedics classes. Lipe was designated as the course instructor and was assisted by Drs. Arthur V. Nilsson, J.G. Anderson, Ordean A. Syverson, Alvin A. Hancock, Edward Burkhart, John Creighton and Mr. Robert Dillman. (16)

[FIGURE 5 OMITTED]

The Research Years of the CSCO

Having completed their organizational efforts, the CSCO began the task of producing research related to their specialty. On February 27, 1958, Hancock wrote a letter to Dewey Anderson, PhD, Executive Director of the Public Affairs Institute in Washington, D.C. The letter contained a brief history of the CSCO and an outline of its research desires. Anderson promptly replied and met with the society on March 7, 1958 at the Statler Hotel in Los Angeles to help start the research program. (31) The group also met with Dr. Douglas Campbell, the referee for the Industrial Accident Commission, on April 8, 1958. After hearing their plans, Campbell stated that the CSCO would need volumes of documented statistics and clinical data if they hoped to realize the dream of insurance recognition spoken of by Dr. Hamilton in March 1954.

[FIGURE 6 OMITTED]

The society began their ambitious research agenda by acquiring the services of Henry Higley, DC, MS (Fig 6), Research Director of the LACC and chairman of the NCA Committee on Research, to act as the society's research advisor. (16) Higley and the CSCO developed a long-range study of clinical evaluation and manipulative procedures for lumbar spine intervertebral disc injuries. (16,26,40) This multi-phase project was funded by the NCA and spanned a period of several years. (40) The first goal on their research agenda was to write a comprehensive review of the literature pertaining to intervertebral disc injuries. Higley was the principal investigator for this project. C. Morgan, MS, and a research team of more than 30 LACC students assisted Higley. This team screened over 3000 journals published primarily between the years 1948-1958. Over 960 documents were included in the final review in which Higley and his team extracted data pertaining to the diagnosis and management of intervertebral disc injuries. The authors critically appraised each paper included in the study, and, when appropriate, pooled the extracted data for statistical analysis. (41,42) The final 206 page report was published as a monograph titled Intervertebral Disc Syndrome. (40,41,43,44)

Higley and the CSCO wished to follow up the literature review with clinical research on intervertebral disc injuries, conducted in multiple centers throughout North America. Higley wrote a Manual of Procedure to clearly outline the proper steps in the clinical research process so that data produced by various facilities would be similar enough to provide valuable information. (45) Sites chosen for the study included the teaching clinics of the following colleges: Canadian Memorial College of Chiropractic, Chiropractic Institute of New York, Lincoln Chiropractic College, LACC, National College of Chiropractic, Northwestern College of Chiropractic, Texas Chiropractic College, and Western States Chiropractic College. (46)

Despite Higley's detailed preparation and the good intentions of the CSCO and the NCA, conducting research in the teaching clinics was exasperating for Higley. Clinicians at the study sites did not understand the detail necessary to produce quality clinical studies, which hampered the progress of their research. Higley pleaded with clinic directors to practice good scientific methods, including not altering data on returning patients, properly recording data, and following the protocols published in the Manual of Procedure, which, regrettably, was rarely referenced by those overseeing the study at the individual institutions. (42,47,48,49) This clinical study also received opposition from school administrators who complained that the study was costing the colleges too much money to continue their involvement. (42,49) Unfortunately, because of the difficulties encountered while conducting the study, the project did not provide the volume of scientific data and valid research that the CSCO had hoped for. However, the investigators published what data they could. In October 1962, the Journal of the NCA published the first reports of the data received from the college clinics, (50) followed by a complete report in 1964. (51) These publications, and the many announcements of the study in the Journal of the NCA, were a huge political success and raised awareness within the profession as to the importance of research.

The problems encountered in running the multi-site clinical study helped early chiropractic researchers to better understand the infrastructure necessary to produce credible research. Before Higley's multi-center study, little research had been conducted within the profession. (52) At that time, battles for state licensure were ongoing, educational standards were under scrutiny, and improved licensing examinations were under development. These activities consumed the limited resources available within the profession. These were the same issues that contributed to the delay of an emergence of chiropractic science, as we know it today, until the 1970s. (53)

The initial research years of the CSCO were successful. Within six years the group was responsible for proposing and supporting several studies that provided valuable data and a better insight into intervertebral disc injuries. During this time, the profession also learned valuable lessons about the infrastructure necessary to conduct credible research and the amount of manpower required to support such an endeavor. One of the long standing benefits of the research years was that those involved in the orthopedics movement were instilled with a value for contributing to the scholarship of the profession, a characteristic that continued to be present in later years as well. (1)

Orthopedics--A Nationwide Specialty

The CSCO's involvement in research and collaboration with the NCA built foundations for acceptance of the orthopedic specialty within the profession on a national level, which spurred the growth of the specialty. Consequently, some of the long time CSCO leaders pursued opportunities for chiropractic orthopedics that expanded beyond California.

The popularity of post-graduate orthopedics training continued to grow, and many doctors registered for these courses, necessitating the offering of courses in numerous locations. (16) By November 1960, and for well over the next decade, Lipe taught the orthopedics program by himself throughout California. (54) He also started a course at the Western States Chiropractic College during 1962, (54,55) and traveled throughout the United States to teach the program (F. Maynard Lipe, interview, January 17, 1995; Leonard Savage, interview, August 17, 1994). Other post-graduate orthopedic programs sprang up across the country during 1959-1960; Dr. Joe Janse began a program at the National College of Chiropractic, and courses were introduced at Northwestern College of Chiropractic (16) and the Chiropractic Institute of New York (F. Maynard Lipe, interview, January 27, 1995). Under Lipe's direction, the orthopedic curriculum was updated and expanded to 240 hours of instruction (A. Bracker, interview, February 17, 1994). He also performed work to standardize the orthopedics curricula across schools offering the program. (42)

Due to the expansion of the movement and extensive political work of Hancock during 1959, the NCA recognized the growing specialty and, in 1959, announced the formation of a new NCA Council on Chiropractic Orthopedics (NCCO) as a result of combining other committees (Fig 2). Founding officers of the new Council are listed in Figure 7. The NCCO possessed high ideals from its inception. In a 1960 publication, Hancock likened the "stagnant" chiropractors in the profession (those not willing to participate in continuing education and update their skills and knowledge) to the dodo bird, which, by not adapting to its changing environment, became extinct. For Hancock, participation in the NCCO and its courses provided tools for chiropractors to use to adapt to the changing times of insurance company approval and recognition. Hancock also listed the NCCO's plans in his article, which focused on efforts to better understand and be accepted within the insurance reimbursement process. Figure 8 presents a summary of these ideas that later were included in article two of the NCCO bylaws. (56)

It was not until the early 1960s that the orthopedists began to clearly delineate their role in the management of orthopedic problems. In 1961, F. Maynard Lipe authored the first published record of a definition of chiropractic orthopedics (F. Maynard Lipe, interview, January 27, 1995). This definition appears in the first part of a two-part article pertaining to low back injuries, published in the Journal of the NCA. (50,51) Lipe wrote: (57)

The success of the orthopedics movement soon produced a bewildering array of organizations, societies and

post-graduate programs in which chiropractors could participate. Soon, efforts of the orthopedics movement turned towards attempts to clarify this conundrum.

Changes in Orthopedic Organizations

A cascade of changes in the names and functions of orthopedic organizations commenced in 1960. Until 1960, the primary function of the CSCO was to conduct postgraduate courses that had been approved by the California Education and Specialty Societies. With the nationwide growth of the orthopedics movement, these responsibilities would soon be extracted from a state organization and transferred to the NCCO. Accordingly, the CSCO changed its focus to become a fraternal organization for chiropractic orthopedists. This change occurred in September 1960 and the CSCO assumed the new name of the American College of Chiropractic Orthopedists (Fig 2). (64) The ACCO's new objectives related to the continued professional development of orthopedists and the orthopedic movement. Seminars and symposia began being held by the ACCO and the group began to support research in the field, efforts that continue today. (1)However, the ACCO would not oversee the post-graduate orthopedics programs that would soon develop into certifying courses in orthopedics.

Changes across the landscape of organized orthopedics also necessitated a restructuring of the NCCO. Because the NCCO was open for membership to any regular member of the NCA, orthopedic specialists wished to create a society exclusively for trained orthopedists. For this purpose, a new organization, the National Society of Chiropractic Orthopedists (NSCO), was born and was open only to dues paying NCCO members who had completed post-graduate programs in chiropractic orthopedics. Only members of the NSCO who, in addition to the post-graduate courses, completed a required internship and residency and passed a certifying exam, would be awarded the distinction of Fellow of the NSCO. (26) These transitions are illustrated in Figure 2.

In order to administer a certifying examination for the NSCO, the NCA Council on Education appointed Hancock, Milton Kronovet and Lipe as the Board of Examiners for the NSCO. They administered the first NSCO qualifying examination for Fellow candidates at the 1961 NCA national convention. Therefore, these three doctors were automatically inducted into the NSCO as its first members. Immediately following the posting of the examination scores, the NSCO elected officers, at which time Alvin Hancock was elected president. (16)

More changes were forthcoming. By 1963, several negotiations to unify the two largest national chiropractic organizations occurred. Consequently, the NCA and a group from the International Chiropractors Association became the American Chiropractic Association (ACA). (58,59) Thus, the former councils of the NCA changed their names and the NCCO became the ACA Council on Chiropractic Orthopedics, which still functions today. (60) In later years, the ACA Council on Chiropractic Orthopedics absorbed the NSCO (Fig 2) and upgraded its instruction and examination procedures. (1,61) These changes eventually lead to the formation of two subgroups of the ACA Council on Chiropractic Orthopedics, namely the ABCO in 1972 (62) and the Academy of Chiropractic Orthopedists (ACO) in 1981. (63) Diplomates of the ABCO could become members of the ACO and be designated Fellows of the ACO (FACO) if they helped support the ACO with financial assistance. 1 Thus, one must be a DABCO in order to become a FACO and the difference is that FACOs make a greater financial contribution to the organization. Figure 2 illustrates these transitions.

Thus, the orthopedics movement initiated by Alvin Hancock included the formation of multiple post-graduate training programs and six different professional organizations over a period of just nine years. These six organizations were eventually amalgamated or changed into the three current organizations that have persisted for nearly 30 years.

Discussion

Comments on Historical Interpretation

The origins of this specialty possess relevance to all chiropractors, as this story unveils one manner in which specialty groups developed in the chiropractic profession and how developments in post-graduate education may become infused into core chiropractic college curricula. The saga of early chiropractic orthopedists also serves as an example of how field practitioners have stimulated research endeavors within the profession.

The research agenda created by the orthopedists and the initial literature review completed by Higley are unique in several ways. First, the research design and methods of Higley's study most closely match, in current terminology, either a qualitative systematic review of the literature or a meta-analysis. The limited technology available for conducting literature searches during the late 1950s would have made this project a daunting task, especially since systematic reviews and meta-analyses did not gain a foothold in the medical literature until the 1970s. (64) Additionally, the Intervertebral Disc Syndrome represents what is most likely the first research publication authored by a chiropractor to ever be indexed in Index Medicus; the citation may be found by using the National Library of Medicine's NLM Gateway search engine (http://gateway.nlm.nih.gov). Unfortunately, the document is also very rare. The only bound copy that we have seen is the original manuscript that is located in the rare book collection at the LACC and only 6 other copies are listed on WorldCat (www.worldcat.org).

Another topic that deserves additional interpretive historical analysis is the ambitious research program led by Henry Higley. Given the ongoing licensing battles, the need for improved educational standards, and recognizing that the school leaders and clinic directors had no formal training in research methodology, (42) it is not surprising that Higley and his team encountered great difficulties in promoting and conducting research. That Higley attempted such an ambitious project and collected enough data to generate a report in this climate is in itself noteworthy. Understanding the barriers to the developing young science of chiropractic magnifies the importance and commitments of the chiropractic orthopedists to support Higley's research and still find the time and energy to publish their own papers.

The development of the chiropractic orthopedic specialty groups should also be interpreted in the context of other changes taking place in health care at the time. For example, medical orthopedics developed in a similar fashion in the United States. Medical education standards and state licensure developments also occurred simultaneously in medicine during the early 1900s. Specialty societies soon formed in medicine, and specialty boards began forming in the 1930s to define the qualifications of specialists. National specialty organizations later formed, and then subspecialties developed within these. Medical orthopedics is an example, demonstrating subspecialties in surgery of the hand and other areas. (65)

While the profession has not germinated subspecialties in chiropractic orthopedics, it has followed a path similar to other medical specialty developments. It was not uncovered in the course of this study if the pioneers of chiropractic orthopedics knew of organizational developments in medical orthopedics. However, it is plausible that they were aware of these changing trends in medicine and tried to replicate this process in chiropractic.

In order for a society to be established and grow members were needed. It seems that some of the requirements for entry into orthopedics organizations were not rigid at the beginning. One of the defining criteria for entry into the NSCO was the completion of an internship and residency in addition to the completion of the post-graduate orthopedics curriculum. (26) No printed or interview data were found that can describe these educational requirements or if the NSCO strictly enforced this requirement. Another interesting point is that the first NSCO members, Hancock, Kronovet and Lipe, were grandfathered into the society. This act set a precedent for the future development of orthopedic specialty groups, as the first orthopedic diplomates were grandfathered into the ABCO in a similar fashion. (1) While such practices do not transpire today, it seems that they were necessary at the time to start these organizations.

An early goal of the chiropractic orthopedic societies was to eventually have orthopedics included in all core curricula at chiropractic colleges. This transpired over time, as many chiropractic college faculty members attended the orthopedics courses and became specialists. These faculty members began integrating their newly gained skills and knowledge into their courses and now all colleges currently teach orthopedics. As a result, all chiropractic colleges eventually included orthopedics in their core curricula. This retrograde educational influence creates some difficulty in differentiating the orthopedist of years past from the general chiropractor of today, since modern day graduates learn a great deal of what was taught in the original post-graduate orthopedics programs. (1) In support of this, one may merely review not only chiropractic college catalogs and curricula, but also definitions of orthopedics provided by the orthopedic organizations. It could be argued that the definition of chiropractic orthopedics originally offered by F. Maynard Lipe and the current definition provided by the ABCO represent the majority of how the chiropractic profession is defined today.

Limitations

It is recognized that some misinterpretations of historical data may have been made while preparing this study. There were some missing periods in the chronology constructed from the primary data; attempts were made to fill these gaps by linking closest data points with information extracted from interviews. Other potential sources of error or bias could include the search strategy used to find data. Since no electronic databases exist that index any of the publications needed for this research, we had to conduct page-by-page hand searches of over 80 years worth of publications. While weary eyes may have resulted in missing an important detail, great care was taken to scan every page systematically for any mentioning of a topic or person related to orthopedics.

It is acknowledged that publications from other organizations, such as the International Chiropractors Association, or other institutions may have contained more and different information than what was found in this research. Given the limited resources available for this project, it was not deemed prudent to attempt an even more exhaustive search of other such publications. Comments from interviewees and consultations with other chiropractic historians confirmed that the majority of information available was most likely included in the publications that were searched. Several attempts to verify this historical account were made in an effort to give appropriate credit to those individuals responsible for advancing the orthopedic movement in its early years. Primary data regarding such individuals were obtained from the printed matter reviewed. These data were confirmed during personal interviews conducted as part of this study. Additionally, earlier research conducted on the social development of chiropractic orthopedics (64) was sent to numerous orthopedists for comment and no private or published corrections regarding the fundamental protagonists of the specialty were provided. Therefore, it is believed that the actual original pioneers are recorded correctly in this paper.

While the social history of chiropractic orthopedics has been reflected in this paper and elsewhere, (1) other topics worthy of historical investigation are still unexplored and therefore have not been included in this study. One such topic is the development of the definition of chiropractic orthopedics from its earliest mentioning in chiropractic publications to the present time. The present research only investigated the definition provided by Lipe in the early 1960s. However, other definitions are found in earlier publications, such as D.D. Palmer's (66) and B.J. Palmer's, (67) that differ from the one by Lipe. Tracing these definitions may provide insight into how chiropractors defined the profession over time. Comparing definitions of chiropractic orthopedics with those of medicine may also demonstrate how or if the practices were different at various times.

Conclusion

The early protagonists of organized chiropractic orthopedics were motivated to improve clinical skills and office management strategies in order to gain a foothold in insurance reimbursement for the chiropractic management of orthopedic problems. The popularity and progress of the orthopedics movement was developed as a post-graduate training program yet resulted in the inclusion of orthopedics in core chiropractic college curricula. This early orthopedic movement was successful in creating a large cadre of chiropractors with enhanced skills to diagnose and treat musculoskeletal conditions in a conservative manner. Early chiropractic orthopedists stimulated and supported noteworthy research projects during the 1960s, which created some of the groundwork for the future modern research movement in the chiropractic profession.

Acknowledgments

This paper is dedicated to our dear friends and collaborators, David S. Wentz, DC and Joseph Keating, Jr, PhD, who contributed much to this research, yet both passed away before its completion. We also appreciate the willingness of several founding members of the orthopedics movement to be interviewed for this research.

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Figure 3 Initial faculty of the first post-graduate chiropractic orthopedics curriculum

Ronald M. Lawrence, DO (course director) Arthur V. Nilsson, DC (anatomy) Robert Dishman, DC, ND (CA State Board of Chiropractic Examiners) Ralph Crawford, DC (CA State Board of Chiropractic Examiners) JG Anderson, DC, ND (neurology) Joseph Berg, DC (roentgenology) James O. Emperingham, DC (roentgenology) E.A. Greenwald, DO (dermatology) Mr. Robert Dillman (jurisprudence) Harry Larson, DO (orthopedics) Lawrence Jones, MD (orthopedics) Alvin A. Hancock, DC (topic not specified)

Figure 7 Founding officers of the NCA Council on Chiropractic Orthopedics

James A. Slocum, DC--president Alvin A. Hancock, DC--vice-president Lyle E. Snavely, DC--secretary Gerald L. Whitten, DC--treasurer

Figure 8 Initial educational and research plans of the National Council on Chiropractic Orthopedics

* Publish articles pertaining to orthopedics in the

Journal of the National Chiropractic Association.

* Prepare loose leaf articles, for mailing to NCCO members, about examination, treatment and office procedures.

* Provide examination forms, exercise charts, and statistical reports to NCCO members.

* Stimulate research in manipulative science

* Promote post-graduate courses at chiropractic colleges about the manipulative approach to orthopedic problems.

* Arrange for an internship and residency program through the NCA's Council on Hospitals and Sanitaria.

Bart N. Green, DC, MSEd * [[dagger]] Claire D. Johnson, DC, MSEd [[double dagger]]

* Chiropractic Division, Department of Physical and Occupational Therapy, Naval Medical Center San Diego, MCAS Miramar Branch Medical Clinic, PO Box 452002, San Diego, CA 92145-2002. Tel: 858-577-9948. bart.green@med.navy.mil

[[dagger]] Associate Editor, National University of Health Sciences, Lombard, IL.

[[double dagger]] Editor, National University of Health Sciences, Lombard, IL. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
It seems probable that the formation of specialty societies
   in California, guiding the specialty instruction of
   the Graduate school of L.A.C.C. will point the way to
   an objective solution to the problems of specialty education.
   These societies, it is believed, will place the
   emphasis where it properly belongs--in the Graduate
   Classes--and remove the pressure for inclusion of
   more than basic subjects in the Undergraduate College.


The need for Orthopedic Specialists, who are academically
   equipped and who have the necessary qualifications
   to handle orthopedic cases is great and urgent.
   Orthopedic cases referred from the general profession,
   insurance carriers and other branches of the healing art
   are wide open to the alert, intelligent Doctor who can
   see opportunity to advance himself and the profession.
   Investigate the curriculum and the hours necessary for
   Certification as a Chiropractic Orthopedist and enroll
   in this advanced class now.


Chiropractic orthopedics shall be considered that
   branch of orthopedics, the purposes of which are, by
   non-cutting techniques, to prevent and correct deformity
   and to preserve and improve the function of bones,
   muscles, joints, and their nerve apparatus, when such
   function is threatened or impaired by defects, lesions,
   or diseases.


Table 1 Primary sources of data for this report.

Publication                 Dates Searched

Journal of the California   Feb 1944-Dec 1954
Chiropractic Association

Chirogram/Chiropractic      May 1939-Dec 1961
Physician

Journal of the National     Jan 1935-Dec 1963
Chiropractic Association

American Chiropractic       Jan 1964-Dec 1970
Association Journal

Minutes of the NCA          1960-1964
Council on Education

Table 2 Curriculum proposal for the first
post-graduate orthopedics curriculum

Topic                   Hours of Instruction

Anatomy                 48
Diagnosis               48
Pathology               36
Corrective procedures   36
Physiology              24
Anesthesiology          12
Jurisprudence           12
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