Introduction
We frequently accept that healthcare practitioners of the past were incorrect in their assumptions and attitudes toward health and the treatment of disease. However, many ancient treatments have therapeutic value. Similarly, some philosophical concepts proposed at the outset of the chiropractic profession can be shown to have scientific merit. In 1910, B.J. Palmer stated, “A common question which Chiropractors and their patients have to face is the question of Retracing.” Described as “going over ground which has already been covered,” the patient under care may “exhibit symptoms which have not manifested themselves for months, or even years. [The patient’s] first impression is that he is becoming worse, but the facts remain that he is retracing the several stages through which his dis-ease progressed in the making.”1 The intent of this article is quite limited. We wish to note that the concept of retracting has been proposed in the chiropractic profession and we propose that the mechanism of ischemia in the nerve root followed by reperfusion might offer at least a partial reason for retracing. We strenuously wish to avoid any involvement or comment on other concepts and our comments are intended to support the very limited scope of the proposed involvement of ischemia and ischemia reperfusion with the observed phenomena of retracing.
DISCUSSION
Historic philosophical perspective
The age of a healthcare procedure or practice does not necessarily determine its effectiveness. While healthcare knowledge and technology have advanced significantly in recent decades, there are instances where traditional or historical healthcare practices and theories have been shown to be beneficial and cost-effective.2–8 Chiropractic is an example.8
An issue that appears rampant in our chiropractic educational centers today is the logical fallacy known as the “argumentum ad novitatem” or, more simply stated, new is always better.9 It is common to assume that newer ideas, technologies, or healthcare practices are superior to older ones because of their novelty. The “appeal to novelty” frequently overlooks the need for evidence and reasoning to support the claim.10
Philosophy provides the foundational framework for the scientific method and the principles of reasoning and logic. It helps define what constitutes valid evidence, how to formulate hypotheses, and how to draw conclusions from data. In a broad sense, philosophy is an activity people undertake when they seek to understand fundamental truths about themselves, the world in which they live, and their relationships to the world and to each other. Philosophy is quite literally “love of wisdom.”11 Philosophy should continually challenge and refine our understanding of science, making it an integral part of the scientific enterprise.
The biological sciences were comparatively rudimentary at the time of D.D. Palmer. Chiropractic philosophy was formed when there were some pretty big holes in healthcare science.12
Today, the gaps may be smaller, but they still exist. We should not be concerned that unbiased advances in science will do anything but help support chiropractic. In one of our philosophy classes, I discuss the hypothesis that there is purpose in the body’s design, including its responses to environmental challenges; and that many of the symptoms that patients express, such as fever, loss of appetite, fatigue, vomiting, and diarrhea, are often adaptive responses, and, as such, enhance survival value. When these things are explained through the lens of Darwinian Medicine,13 students listen. When explained that D.D. Palmer expressed these opinions over a hundred years previously (figure 1) - the response is surprise. The appropriate response should be, “But of course he did.”
D.D. Palmer’s son, B.J. Palmer noted that the question naturally arises in the mind of the patient as to why the adjuster cannot return the vertebra immediately to its normal position and thus immediately restore the tissue to a healthy state.1 (Figure 2) Many chiropractors have had the experience of having a new patient who seeks care for a chronic condition with the expectation that a single adjustment will resolve it. This is not the typical progression. The longer a condition exists, the longer it frequently takes to resolve.
Chronic problems that are resolved quickly are presented at homecomings and chiropractic conventions as miracle cases. We should oppose the term chiropractic miracle case. The Oxford Dictionary defines a miracle as a highly improbable or extraordinary event.14 This would suggest that a positive clinical outcome from adjusting a patient is what is least expected to occur.
Any chiropractor with even rudimentary clinical experience knows that the patient’s journey from disease back to health is not always a smooth transition. Patients might make quick progress followed by what seems like a plateau. They may note stiffness or soreness after their initial adjustment. They might even take what seems like a step backward in their progress at times. Patients consequently may believe they are getting worse. Sadly, the patient may even elect to discontinue care. Is this a failure of chiropractic? Or can this bumpy transition frequently be expected? Did our progenitors account for this? Absolutely. They referred to it as retracing. (Figure 3)
B.J. Palmer wrote, “A common question which Chiropractors and their patients have to face is the question of Retracing.” He describes retracing as “going over ground which has already been covered.” The patient under care may “exhibit symptoms which have not manifested themselves for months, or even years. [The patient’s] first impression is that he is becoming worse; but the facts remain that he is retracing the several stages through which his dis-ease progressed in the making.”15 (Figure 4)
Stephenson added to the concept when he defined retracing as the course of restoration from dis-ease back to health. “Every case retraces, for if there is a departure from health, there must be a return to it if there is restoration. When a case retraces, it passes back through the successive steps, in reverse order, that it passed through in getting worse.”16 (Figure 5)
In B.J. Palmer’s pamphlet on retracing he notes that for a tissue cell to be healthy it must be supplied with 3 essentials: nutrition in the proper quantity and quality, vital energy through the nervous system in proper quantity and quality, and oxygen in the proper quantity.1 Was he correct? Is there a current scientific explanation that supports this clinical phenomenon? Are some of the scientific gaps in our knowledge in the past filled to the point that they are now able to explain our philosophical theories? What impact does chiropractic adjustment have on the process?
Searching the Literature
The Palmer Green books represent the textbooks used at the Palmer School during the formative years of the profession’s development. They include fundamental texts that explore chiropractic philosophy. The Green Books have been digitized, allowing them to be searched using keywords. The keyword retracing was used to search the Palmer Green Books. In addition the Palmer Archives also searched their collections to obtain other sources in which the concept of retracing was addressed. Finally, despite one of our familiarity with the field as a professor at a chiropractic college whose area of instruction includes chiropractic philosophy, others, with advanced standing in chiropractic philosophy were contacted to determine if any obscure references might be obtained.
Modern scientific support
Basic Damage Proposal
The field of ischemia-reperfusion injury is of significant interest to the scientific community. A search of PubMed in March 2024 using the terms ischemia, reperfusion, injury returned 74,861 results. During ischemia-reperfusion injury, free radicals are generated in the ischemia phase and significantly increase during the reperfusion phase.17,18 Di Meo and Venditti noted, “Free radicals are chemical species (atoms, molecules or ions) containing one or more unpaired electrons in their external orbitals and generally display a remarkable activity.”19 Sun et al. stated that, “Among all possible pathological mechanisms of ischemia-reperfusion injury, free radical damage (mainly oxidative/nitrosative stress injury) has been found to play a key role in the process.”17 When discussing peripheral nerve compression Gao found that ischemia and mechanical injury are the primary injury factors in compressed nerves and that nerve compression causes nerve ischemia.20 In peripheral nerves oxidative injury during reperfusion caused fiber degeneration and affected nerve function, however, over time it allowed nerve fibers to regenerate.21
Nerve roots can be compressed mechanically by the disc.22 In a study on discectomy affecting nerve roots, the authors concluded that, “The results of the current study suggest that immediate relief from pain and resolution of neurologic deficits soon after surgery are the result of early recovery from nerve root ischemia after discectomy, and that ischemia caused by mechanical nerve root compression is mainly related to the mechanisms underlying sciatic pain production and neurologic deficits.”23
A complete discussion of free radicals and the damage they can cause during ischemia-reperfusion is beyond the scope of this article, but it is noteworthy that ischemia-reperfusion injury is associated with clinical manifestations.24 Olmarker has shown that as little as 30mg of pressure applied to the venules or 40mg of pressure applied to the capillaries in the porcine cauda equina can stop blood flow in its nerve roots.25 This pressure will produce ischemia in the nerve root with its accompanying free radical production. No matter what the mechanism that produces pressure on the nerve root, it would appear that sufficient pressure on either the venules or the capillaries would produce ischemia in the nerve root.
Retracing Process
Damage can begin as free radicals increase during ischemia. The damage increases during reperfusion as the number of free radicals generated increases with reperfusion.17 As the chiropractic profession has traditionally been greatly concerned with removing nerve interference, a typical scenario might develop whereby a subluxation causes a disc to press on a nerve root. The clinician delivers a chiropractic adjustment. This adjustment results in removal of pressure on the nerve root; the removal of this pressure allows normal blood flow to return to the nerve root, resulting in a further increase in the free radicals along with the damage they can cause. Although this removal of pressure is a necessary step in the healing process,21 it does have the problems related to ischemia reperfusion injury.17
The course of the condition could unfold as follows: pressure is placed upon the nerve root. This pressure stops or reduces normal blood flow to the nerve root and the pain starts and over time increases, eventually reaching its maximum of symptoms. The condition progresses and there is a continued loss of blood flow and a continued generation of free radicals producing damage to the nerve root, resulting in a continuation of symptoms. The patient receives an adjustment that removes the nerve root pressure affecting the blood flow in the nerve root. Reperfusion occurs with blood returning to the ischemic nerve root. With the reperfusion, there is an increase in damaging free radicals and a corresponding flaring of symptoms. The initial sudden increase in free radicals decreases as the blood continues to flow to the nerve root and the nerve root starts to heal. Healing takes place and the symptoms slowly recede and go away.
To the clinician and the patient, the course of the condition is a start of symptoms progressing until the height of symptoms is reached. This is a progression from least symptoms to maximum symptoms. The symptoms stabilize. Then there is a worsening of symptoms following the adjustment followed by a slow progressing back toward normal. This is a progression of symptoms from greatest to least.
This could also be applied to conditions caused by subluxations that are not related to pain. Therefore, there was an apparent “retracing” of the condition back through its phases of symptomology, giving rise to the historical concept of “retracing.” This would be an approximation of Stephenson’s16 explanation of retracing: when a case retraces, it passes back through the successive steps, in reverse order, that it passed through in getting worse.
Denham Harmon proposed the free radical theory of aging in the 1950s.26 The basic thrust of this theory is that free radicals, through oxidative damage, may offer at least a partial reason for aging. More directly related to the present discussion, pressure on a nerve root may affect the blood vessels in such a manner as to reduce or stop blood flow in the nerve root.25 This would result in free radical production.17 As the chiropractic profession has traditionally been greatly concerned with removing nerve interference, a scenario might develop. The clinician delivers a chiropractic adjustment; this adjustment results in removal of pressure on the nerve root; the removal of this pressure allows normal blood flow to return to the nerve root resulting in a further increase in the free radicals along with the damage they can cause. Although, this removal of pressure is a necessary step in the healing process, it does have the problems related to ischemia reperfusion injury.21
At a practical level, this type of nerve root pressure might be caused by a bulging intervertebral disc contacting the nerve root.21,23The disc has historically been of great interest to the chiropractic profession. The Gonstead methodology, which Cooperstein has called a “big technique” because of the number of chiropractic clinicians who use at least some of its methods,27 is interested in the disc being a central part of chiropractic care. In fact, the book Gonstead Chiropractic Science & Art: The Chiropractic Methodology of Clarence S. Gonstead, (known in Gonstead circles as “The Chapters”) states, “The entire basis of the Gonstead methodology evolves around the intervertebral disc.”28 If a chiropractic clinician treats a patient who suffers from pressure on a nerve, it is plausible that a reduction of blood flow and an increase of free radicals have occurred. This adjustment results in removal of pressure on the nerve root perhaps caused by an intervertebral disc pressing on the nerve root. The removal of this pressure allows normal blood flow to return to the nerve root, resulting in the increase in free radicals along with the damage they can cause. As Iida stated when looking at ischemia followed by reperfusion in the sciatic nerve roots of rats, “It was concluded that reperfusion, by oxidative injury, worsened nerve function and aggravated fiber degeneration, but in a longer time frame, permitted fiber regeneration to occur.”21
CONCLUSION
This scenario might appear to the patient and the clinician as though the patient developed a condition due to nerve pressure and then following the release of that nerve pressure progressed back through the symptoms of the condition until returning to health. This process would closely resemble the historical philosophical concept of retracing which B.J. Palmer and other chiropractors such as Stephenson discussed and might give us a scientific reason for the observed phenomena discussed by chiropractors as retracing.
It would certainly be an error to suggest that this is a complete explanation that would apply in every case. However, it is certainly a plausible explanation that could apply to many cases. It is important that history is not viewed as some dead and best forgotten occurrences that were commented upon by those who knew less than we do today. History can give us insights that can make today and the future better.