The Historic Background of Osteopathic Medicine

Between the founding of the first permanent English colony at Jamestown, in 1607, and the establishment of the first American collegiate curriculum in medicine, in Philadelphia in 1765 ¹, lay 158 years. During that time medical practice in the Colonies was carried on by several healing groups. There were some physicians from the formal schools of Europe, but they were comparatively few; as the elite from among the medical men, they usually practiced among the upper classes and were perhaps less likely to emigrate than those with less secure positions.¹ More plentiful were the barber-surgeons, apothecaries, and lay practitioners.

In England, physicians sometimes began their training by apprenticeship, but they usually went on to earn university degrees. These practitioners were considered gentlemen and scholars. They did not work with their hands, as did the surgeons, or engage in trade, as did the apothecaries, though these distinctions did break down in rural areas.²

Surgeons were prepared by hospital and apprenticeship training. Although their work was required by all social classes, their status was lower than that of the physician.

Apothecaries also were trained by apprenticeship and sometimes in hospitals. They sold drugs, and in time they came to be regarded as a type of general practitioner. As their fees came from sales rather than consultations, they probably were tempted to prescribe heavily, and perhaps their reputation as hard-dosing Islanders was in some measure deserved.

In the Colonies, as in rural England, the distinctions tended to vanish, and the communities sought medical help from the best person available. Particularly on the frontier, but even in Colonial cities, clergymen often added medical practice to their duties. The Rev Cotton Mather was a prominent example of such persons; at one point he felt sure enough of himself to promote inoculation for smallpox, over the objections of the only MD in Boston. Midwives were a standard part of the medical scene. But almost anyone might practice medicine, whether from a smattering of medical training and a good bit of folklore, or from a reputation based on a single remarkable cure.³

As long as frontier conditions lasted in this country, medical practitioners usually had to sustain themselves with some business other than medicine. People tended to dose themselves and call for help only in emergencies. The practitioner's success tended to depend on the degree of confidence he could inspire, not on any formal credentials. This confidence was based on published or oral testimonials of cures, which might be a result of experience, but might also result from a special knack or reportedly from divine inspiration.³

In England the average term for medical apprenticeship was seven years; in America, from Colonial times through the nineteenth century, it was three or four years. Even this was by no means consistent; as late as 1876 one observer complained that in nine out of ten cases the apprenticeship consisted of little more than the registry of the student's name in the doctor's office.⁴

The first American medical school, as noted above, was founded in 1765, in Philadelphia. Before 1800 there were ten medical schools, all in the East. In these earlier days ideals were high. The collegiate faculties, typically made up of European university graduates, usually expressed opposition to the apprentice system. A talk at the new college in Philadelphia in 1765 contained disparaging remarks about the doctor who wished at the same time to be physician, surgeon, obstetrician, apothecary, and dentist; a division of labor was considered good, and the physicians to be trained at that institution were to be gentlemen already able to read Latin, Greek, and French, and acquainted with mathematics and the sciences.⁵

Even if they had wanted to do so, the graduates of the early medical schools could not begin to serve the rapidly growing population of the United States. Graduates were few in numbers, and a shortage of textbooks and teaching materials made it difficult to enlarge the classes. Wars intervened, requiring the services of many. The pluralistic state of medical practice led to competition and professional quarrels.

By the 1800s, there was even greater complexity and confusion in the medical professions. Besides the differing educational routes to varying divisions of healing, there came to be several schools of healing as well. These ranged from outright quackery, through folk and herbal healing, to such educated but dissident groups as homeopathy.

Some of this diversity has been linked with the early nineteenth century movement to praise the rights and abilities of the common man; some, to the practical problems of the frontier, which made regulation virtually impossible.1 Whatever the reason, the nineteenth century was characterized by a tremendous growth in numbers of medical schools and an almost total lack of legislative regulation for medical practice.

Some early medical schools were university connected, but very few of these were initiated by trustees and run by university-paid faculty. Far commoner was the plan whereby self-organized groups of practitioners contacted a college or university and asked to be accepted as an adult medical department. The college accepted because the offer meant an opportunity to expand, and all it had to do was lend its name and award the degrees. The medical faculty operated very much as an independent proprietary college might, often not even in the same location or city as the college. Some of these in due course became bona fide university departments; others became independent medical colleges. Some schools were sponsored by professional societies, but the largest group was the independent proprietary schools.¹

The education given by medical schools in the 1800s cannot be considered in the same way as medical education is considered today. Major reasons were lack of uniform standards and the uneven quality of entering students. At Harvard in 1869, Charles Eliot tried to institute written examinations for medical degrees, but the director of the medical school was opposed, asserting with little exaggeration that a majority of the students could hardly write.6 It was said that many schools virtually waived entrance and exit requirements in their rivalry for enrollments.⁶

Over 400 American medical schools were in operation by the time Flexner did his landmark study. Even by the late nineteenth century, the atmosphere of medical education was one of intense rivalry between medical faculties, of numerous students hearing didactic lectures during short academic terms, of clinical demonstrations in large amphitheaters, and of large profits for the school's sponsors.⁷ Attendance at these schools might supplement an apprenticeship in a well-motivated student,⁴ but there were few rules.

The earliest attempts at regulation of the healing arts came through the professional societies, whose first means of control was to limit the ability of unqualified persons to sue for fees. Some legislative support was given to this effort early in the late eighteenth century, but in the pre-Civil War period nearly all such laws were repealed. The decisive reforms came between 1880 and 1910. During this period effective state licensing boards were developed. The example of Johns Hopkins University Hospital and Medical School had widespread influence. Finally, the Flexner report resulted in the closing of many poor medical schools.

Concerning the nineteenth century situation, it might be noted that, in describing the proprietary schools, Flexner later said: Eminent men developed somehow even in the mess we have described. He goes on to cite W.H. Welch: One can decry the system of those days--the inadequate preliminary requirements, the short courses, the faulty arrangement of the curriculum, the dominance of the didactic lecture, the meager appliances for demonstrative and practical instruction--but the results were better than the system.⁸

The osteopathic profession began with one man, Dr Andrew Taylor Still, who had an idea which he thought might improve the medical practice of his day. He first articulated that idea to himself, in Kansas, in 1874.⁹ It was, at that time, a seminal thought: that the human body has much in common with a machine, one which ought to function well if it is mechanically sound.

A.T. Still was a typical frontier doctor, having been trained through apprenticeship, with some medical lectures added later. Like nearly all frontier doctors,¹⁰ he did many things besides practice medicine: farming, mechanical work, and fighting in the Civil War. His medical practice included caring for both settlers and Indians. He faced the epidemics of his day: cholera, malaria, pneumonia, smallpox, diphtheria, tuberculosis, and--the one that carried off several of his own children--spinal meningitis.

Still's new system promised simply to support health, which on the surface would not seem controversial. But, as we have seen, this was a time of multiple schools of healing. The young American Medical Association, trying to bring some order to a chaotic scene, simply condemned all groups except its own.⁶ On the frontier, where organizational pressure was not yet so pervasive, there still was medical competition and a mistrust of new ideas. Still tried to present his ideas through the Baldwin and Baker University, in Lawrence, Kansas, an institution he and his family had helped to found. He could obtain no hearing. Neither could he persuade the thinking people of his town to listen seriously.

Traditional medicine was deemed to be respectable, and very soon A.T. Still was not. His clergyman brother told the family that Still had lost his mind and his supply of truth-loving manhood.⁹ Still's talk no doubt did sound a little like raving; he spoke in a rambling style and used many metaphors, after the custom of his time. The situation worsened when he cured someone by manipulation and the local church people attributed his success to the devil.

By force of circumstance, Still became an itinerant doctor, first in Kansas and then in Missouri. He tried out his mechanical skills, and he talked to anyone who would listen about his new science, which centered around treating the body by improving its natural functions. He continued to use some drugs at first, but gradually he found that he was getting good results without them. In time he came to condemn nearly all the drugs being used in his day.

Still's treatment methods, which included manipulation designed to improve circulation and to correct altered mechanics, began to show results. In time he was able to stay in Kirksville, Missouri, letting the patients come to him. He became busier, and people began to speak of him with respect if not with understanding. Gradually, he began to teach his children and a few others what he knew about his science, which he had named osteopathy.

In due course, there was a need for a school where osteopathic medicine could be taught. The American School of Osteopathy was chartered in 1892, and a class of at least 17 was enrolled.11 Early students learned anatomy and physiology from Dr William Smith, a Scotsman who had studied medicine in Edinburgh and had become interested in osteopathic medicine while traveling in the United States as a representative for a medical instruments company. A.T. Still taught osteopathic practice, by lecture and demonstration and through practice with his own patients.

The school's second class, including most of the members of the first class who returned for a second year, was larger. The number of patients was larger as well. In succeeding years classes and patient loads continued to increase. New buildings went up, and curricula became more extensive and better organized.

One of the early curricula was described as follows:

The course of study extends over two years, and is divided into four terms of five months each.

The first term is devoted to Descriptive Anatomy, including Osteology, Syndesmology and Myology; lectures on Histology illustrated by micro-stereopticon; the principles of General Inorganic Chemistry, Physics and Toxicology.

The second term includes Descriptive and Regional Anatomy with demonstrations; didactic and laboratory work in Histology; Physiology and physiological demonstrations; Physiological Chemistry and Urinalysis; Principles of Osteopathy; Clinical Demonstrations in Osteopathy.

The third term includes Demonstrations in Regional Anatomy; Physiology and Physiological Demonstrations; lectures on Pathology illustrated Hycro-stereopticon; Symptomatology; Bacteriology; Physiological Psychology; Clinical Demonstrations in Osteopathy and Osteopathic diagnosis and therapeutics.

The fourth term includes Symptomatology; Surgery; didactic and laboratory work in Pathology; Psycho-Pathology and Psycho-Therapeutics; Gynecology; Obstetrics; Hygiene and Public Health; Venereal diseases; Medical Jurisprudence; Dietetics; Clinical Demonstrations; Osteopathic and operative clinics.¹²

By 1896 there were 66 graduates in the field; but with the starting of new schools in other centers, by the winter of 1896-97 there were about 430 students in osteopathic schools known to be concerned about educational quality.¹³ In addition, there were schools of doubtful character.

By that time, also, there was cause for concern regarding the licensing of DOs in various states; opposition to osteopathic practice had mounted, leading even to arrest in some places. A favorable court decision in Akron, Ohio, provided a helpful precedent, but there was a clear need for legislative recognition.

The first licensing law was passed in Vermont in 1896; at the same time, legislative attempts were being made in Missouri and in other places.^11,14

In 1897, a group in Kirksville organized the American Association for the Advancement of Osteopathy; some months later the Associated Colleges of Osteopathy was formed. Concern for educational standards ranked high on the agendas of both organizations. The American Association for the Advancement of Osteopathy, which was reorganized in 1901 as the American Osteopathic Association, limited its membership to DOs from recognized schools; and it took steps to produce a code of ethics and to support the development of the profession in terms of lawful professional recognition and service to the sick.

The succeeding years saw major growth and spread of the osteopathic profession, accompanied by its legal recognition. Professional meetings and publications continued the educational process, and organized research programs were begun. Several of the early schools were consolidated so that there were fewer than a dozen, and the first osteopathic hospitals were built.

Formal standards for approval of osteopathic colleges were adopted by the American Osteopathic Association in 1902; the following year they were enforced by on-site inspection. The standard course was increased from two to three years in 1905; it was increased again, in 1915, from three to four years.¹⁵

Although the original charter of the American School of Osteopathy permitted the teaching of surgery, it seemingly was not included in the school's earliest courses. However, by 1901, Still wrote that the osteopathic physician should be and is taught to do all operative surgery.¹⁶ By 1906, his American School of Osteopathy had its own hospital. There is evidence that Still himself did certain types of surgery, while referring other types to surgeons who were more expert.¹⁷

The development of hospital-based practice came more slowly than did office-based practice. The American College of Osteopathic Surgeons was formed in 1926, the American Osteopathic Hospital Association in 1934.¹⁸ Although Kirksville had one of the earliest x-ray machines west of the Mississippi (1898)¹⁹, it was not until 1939 that a specialty board in radiology was set up; and it took two more years for a specialty college to become organized.15 Orthopedic surgeons organized themselves in 1941; anesthesiologists in 1947.¹⁵

The first inspection and approval of hospitals for intern training by the American Osteopathic Association took place in 1936. In 1939, the Advisory Board for Osteopathic Specialists was formed; by 1945 there were 11 specialty boards. In 1947, osteopathic hospitals were approved by the American Osteopathic Association for residency training for the first time, though obviously graduate training had been going on previously.¹⁵

Research was a sporadic feature of the osteopathic profession from its earliest days.¹⁶ An early document describes experiments on the effects of spinal stimulation and inhibition of anesthetized dogs, which took place in Kirksville the winter of 1898-99.²⁰ Early studies, with some exceptions, tended towards the idea of proving osteopathic concepts; gradually the emphasis shifted towards an impartial search for general scientific knowledge. In large measure, the shift in research emphasis paralleled the growth in osteopathic medical education. In pre-Flexner days, Midwestern medical education in general was charged with failing to connect the laboratory with the clinic.¹⁶ The change came partly through conscious effort and partly through the addition of preprofessional educational requirements, which prepared students to understand and question the work being done in the laboratory. Preprofessional requirements for the osteopathic profession came earlier in some schools than in others. From the standpoint of the standards of the American Osteopathic Association, however, the requirement for preprofessional training was one year in 1939, two years in 1940, and three years in 1958.¹⁵ Today, virtually all colleges of osteopathic medicine require at least a baccalaureate degree, and a large percentage of matriculants possess advanced degrees.

Research funding originally was provided by the schools or by the individuals doing the work. Then support came through the American Osteopathic Association or one of its philanthropic affiliates, in combination with the schools. In recent years, funding has come from all the usual support sources for biomedical research. Research topics now encompass a broad range of interest; researchers report both at the usual scientific meetings for their fields and at an annual conference sponsored by the American Osteopathic Association. Research funded from within the osteopathic profession itself concentrates on questions distinctive to DOs.

Growth in numbers of osteopathic physicians in the post-Flexner era was slow but steady. The progress of licensing legislation, and the consequent growth of hospitals, made it more attractive for DOs to settle in some states than in others; so early concentrations of osteopathic physicians and institutions developed in California, Michigan, Ohio, Pennsylvania, Missouri, Arizona, Florida, Texas, New Jersey, and New York.

A landmark court decision in Audrain County, Missouri, in 1950, established the right of DOs to practice in public hospitals as complete physicians and surgeons. This helped to provide opportunities for DOs in places where there were no osteopathic hospitals. Then joint-staff hospitals became commonplace; osteopathic physicians now serve on the staffs of virtually all hospitals.

A long fight for recognition of DOs by the uniformed services reached resolution in the middle 1950s. Osteopathic physicians, who in two world wars had been drafted but not permitted to serve as medical officers, obtained a hearing through the Armed Services Subcommittee of the U.S. Senate. As a result of that hearing, legislation was enacted which made DOs eligible for military commissions. Because of the opposition of organized medicine, this law was not implemented for another ten years; by 1967, however, DOs were called and accepted into the service on the same basis as MDs.²¹

The drive to end discrimination accelerated at mid-century. Although each state had some form of legislative recognition of DOs, the goal became full-practice rights. This goal was reached for all states in 1973. By that time, the osteopathic profession had temporarily lost a state. In 1962, as a culmination of several events, the California Osteopathic Association merged with the California Medical Association, and the College of Osteopathic Physicians and Surgeons became an allopathic medical school. A high proportion of California's 2500 DOs accepted MD degrees awarded after attendance at a brief seminar and payment of a $65 fee. As a result of a public referendum, licensing of any new DOs in that state was prohibited.

At that point of crisis, many were predicting a speedy demise for the osteopathic profession. Loss of the largest state group, of one of the six colleges, of many training hospitals, and of public identity through a referendum made the future look bleak.

A long court fight was begun in California by the DOs who remained loyal to their profession; this was resolved in 1974 by the California Supreme Court, which ruled that new licenses could indeed be issued. A new college was chartered in California, and the profession once again flourished there.

As a national consensus developed over the importance of primary care, osteopathic medicine reached a new kind of public notice because of its community-based educational and practice styles. New colleges began to be formed and built, largely with public funds; at present there are 19 in operation. These, plus increased enrollment in older schools, account for significant increases in the number of DOs (see statistical tables elsewhere in this book).

In 1998, following a four-year transition period, all osteopathic internships and residencies had joined consortia training groups known as osteopathic postdoctoral training institutions (OPTI).

In the late 1800s, there were four major schools of medical practice: homeopathic, eclectic, allopathic, and osteopathic. The climate was competitive, and the professional differences were bitter. In due course the homeopathic and eclectic groups faded, leaving only the osteopathic and allopathic medical groups. Relations between these groups have improved greatly in recent years, but the American Osteopathic Association has repeatedly stated its intention to remain separate and distinctive.²² Cooperation between the groups has become cordial on issues related to the public health.

References

1. Norwood, W.F.: Medical education in the United States before 1900, in O'Malley, C.D., ed.: The history of medical education. UCLA Forum in Medical Sciences, no 12. 1970: University of California Press, Berkeley, pp. 463ff.

2. Shryock, R.H.: Medicine and society in America, 1660-1860. 1960: Great Seal Books, Cornell University Press, Ithaca, NY.

3. Kett, J.R.: The formation of the American medical profession: The role of institutions, 1780-1860. 1968: Yale University Press, New Haven.

4. Brieger, G.H.: Introduction, in Medical America in the nineteenth century: Readings from the literature. 1972: The Johns Hopkins Press, Baltimore.

5. Snapper, I.: Meditations on medicine and medical education, past and present. 1956: Grune & Stratton, New York.

6. Burrow, J.G.: AMA: voice of American medicine. 1963: The Johns Hopkins Press, Baltimore.

7. Flexner A: Medical education in the United States and Canada; a report to the Carnegie Foundation for the advancement of teaching. 1910: The Merrymount Press, Boston.

8. Flexner, A.: Medical education: A comparative study. 1910: The Macmillan Co., New York, 1925, p. 42.

9. Still, A.T.: Autobiography of Andrew Taylor Still. 1897: Published by the author, Kirksville, MO.

10. Dick, E.: The sod-house frontier. 1952: Johnsen Publishing Co, Lincoln, NB.

11. Booth, E.R.: History of osteopathy and twentieth-century medical practice. 1924: The Caxton Press, Cincinnati.

12. Catalogue of the American School of Osteopathy, session of 1899-1900. Seventh annual announcement. Kirksville, MO.

13. Hulett, C.M.T.: Historical sketch of the AAAO. JAOA 1:1, Sep 01.

14. Hildreth, A.G.: The lengthening shadow of Dr. Andrew Taylor Still. 1942: Publishers: Mrs A.G. Hildreth, Macon, MO, and Mrs A.E. Van Vleck, Paw Paw, MI.

15. AOA history: Dates, events and people. AOA Yearbook and Directory of Osteopathic Physicians. Current edition. American Osteopathic Association, Chicago [compiled from AOA archives].

16. Cole, W.V.: The development of osteopathic education and research. 1958: Academy of Applied Osteopathy, Year Book 1958. Academy of Applied Osteopathy, Carmel, CA, pp. 117ff.

17. Peterson, B.: The memoirs of Dr. Charles Still; IV. A postscript. THE DO 1975; 15(9):25-6, June.

18. History of the American College of Osteopathic Surgeons. 1980 Membership Directory and Bylaws. American College of Osteopathic Surgeons, Coral Gables, FL, pp. 4-8.

19. Peterson, B.: 1898: Radiology in Kirksville. JAOA 1974; 74:167-72, Oct.

20. Peterson, B.: Time capsule: How old is osteopathic research? THE DO 1978; 19(4):24-6, Dec.

21. Kleinheksel, K.: Time capsule: How DOs gained commissions. THE DO 1980; 20(8):25-32, Apr.

22. AOA position papers. AOA Yearbook and Directory of Osteopathic Physicians, current edition.