3. Internal controversies on the development of osteopathy and on osteopaths’ professional scope

Dr A.T. Still had conceived osteopathy as a “drug-free system,” an alternative not only to allopathic medicine but also to other forms of therapy of his time. In fact, in the nineteenth-century United States there was a pluralistic system that included homeopathy and eclectic medicine alongside orthodox medicine, but also admitted other medical disciplines, like botanical medicine, hydrotherapy, Christian Science, magnetism, swedenborgianism, together with European, African, and Native American folk medicine,  bonesetters’ manipulations, home remedies, and all sorts of concoctions peddled on market stalls by quacks and barkers.¹ In addition, a substantial slice of the market was taken by elixirs produced by private companies holding secret patents (the so-called patent medicines), which were highly advertized and sold in pharmacies or by mail order. These elixirs thrived until 1906, when a report came out that prompted the U.S. administration to enact new laws to curb this phenomenon.²

Ever since the mind of the 27-year-old Still – fresh from his apprenticeship with his father and active as a regular physician – had been taken aback by Major Abbott‘s prediction that some day something else would have taken the place of allopathy, eclecticism, and homeopathy,³ Still had looked into the different kinds of therapy of his time, examining both their theory and their practice, coming to the conclusion that they were mostly based on guessing and on useless, if not harmful, remedies. The science of osteopathy, on the other hand, proved to be effective in managing also conditions such as fever, hemorrhagic diarrhea, measles and diphtheria without resorting to external agents.⁴

On the basis of these assumptions, throughout his life, Still emphasized how important it was for osteopaths to distinguish themselves from other physicians, so much so that, initially, the title conferred by the ASO was “Diplomate of Osteopathy” and it was only from June 1900 that A.T. Still reluctantly allowed it to be changed into “Doctor of Osteopathy.”⁵

Nonetheless, even before the end of the nineteenth century, strong controversies came to surface within the osteopathic community, mainly concerning the study of pharmacology and the role of DOs in the health care system. Two different factions then emerged, the “broad osteopaths” and the pure “lesion osteopaths”. The latter adhered faithfully to Still‘s traditional idea, based on the hunt for lesions and on the exclusive administration of osteopathic treatments for all sorts of diseases.^6:69-84 On the other hand, the advocates of “broad osteopathy” claimed that a good physician should use all the best tools at his disposal in order to help his or her patients, including allopathic drugs when necessary.

In 1897, ASO introduced some teachings on obstetrics and surgery, and consequently some notions concerning the use of anesthetics, antiseptics, and antidotes – these types of drugs were known as “osteopathic pharmacology (osteopathic materia medica).” While these subjects were introduced in all schools as early as 1903, there was no common ground in respect to the so-called adjuncts (eg, hydrotherapy, exercise, therapeutic suggestion, electrotherapy, diet, etc.), so each school decided whether or not including them in their curricula. In contrast, the study of pharmacology (a medical subject) was banned from the curriculum of osteopathic colleges on pain of loss of recognition by the ACO, since treatments based on chemicals, vaccines and serums were unacceptable from the point of view of the osteopathic philosophy.

This gave a lot of leeway to the orthodox physicians, both in the courtrooms, where they dragged osteopaths accusing them of abuse of the profession, and in the chambers where the legislatures of each federated state were debated. The American Medical Association (AMA) had been established in 1847 for the purpose of unifying the profession and imposing itself on other forms of medicine. Its members were referred to as “MDs” (the abbreviation for the Latin Medicinae Doctor, or simply Medical Doctor), while osteopaths were distinguished by the initials “DO.”

At the end of the nineteenth century the AMA had not yet gained a dominant position in the health care system, therefore, the existing historical and social conditions allowed osteopaths to celebrate their first successes in the battle for recognition, starting from 1895. From the beginning, however, AMA representatives argued that DOs’ training was not comprehensive and therefore it could not compare with MDs’ training.

This fueled the already lively ongoing discussions between “pure” osteopaths and “broad” ones.

In 1899 John Martin Littlejohn, who at the time was Dean of the ASO and about to complete his osteopathic training, asked the school’s leadership to change the title of “DO” into “MD (Osteopathic).” Dr Still and part of the faculty found this request unacceptable. As a consequence the three Littlejohn brothers were removed from the ASO, along with Dr William Smith and other teachers (including several MD graduates) who did not accept a direction which, in their opinion, was too conservative. The following year the Littlejohn brothers founded the American College of Osteopathic Medicine and Surgery in Chicago, an institute that was admitted among the schools recognized by the ACO, an association of osteopathic colleges active since 1898.

By 1901, osteopathy had gained recognition in 15 U.S. states: this meant that DOs coming out of school had to pass state examinations held by medical boards. This resulted in an impetus to improve and lengthen the schools’ training courses, prompting the ACO to mandate the extension of the curriculum from 2 to 3 years by 1904. Nevertheless, such a decision could put the schools at risk; in fact, osteopathic training institutions depended almost exclusively on student fees, therefore  a decrease in freshmen’s enrolments, discouraged by the longer training courses, could lead to their closure.

Controversies over the role of osteopaths continued to flare up, both inside the single schools and, consequently, in the AOA itself. The advances in orthodox medicine and the availability of prophylactic and therapeutic therapies, achieving excellent results in treating diseases such as rabies, diphtheria, tetanus, cholera, plague, and typhoid, were some of the causes at the basis of the discussion. Many osteopaths argued that the refusal to resort to such remedies seemed to them anachronistic if not downright criminal,^6:76 and justified the accusations of sectarianism and cultism so often moved against osteopathy.

The AOA continued to defend the more traditional ideas of osteopathy. For example, during the 1909 annual convention, the request of three schools to add a fourth year to the curriculum was rejected, with the intention of awarding their graduates the title of DO at the end of the three-year period and the title of MD at the end of an additional year.^7:36;115-118

The spirited discussion continued with numerous articles and letters pubblished in the Journal of the American Osteopathic Association,^{7:115-118;149-151;159-163;174-181;195-197;255-256;278-284;393-395;405-407;415-421;456-7;486-89;532;533-34;541} however, in 1910, the faction in favor of keeping osteopathy separate from allopathic medicine prevailed again.⁸

The debate between “pure” and “broad” osteopaths continued to rage in the following decades, fueled in part by the pressing request for more stringent standards that involved the entire U.S. health care system, and remained a key point in the history of the  profession.