6. The 1920s and the historic decision of the AOA

The events causing the turning point that in 1929 determined the beginning and the evolution towards an osteopathic medicine parallel to orthodox medicine, with a similar training and scope of practice.

After the end of World War I, orthodox medical colleges received many benefits, like tax breaks, donations and other public and private fundings. As a consequence they expanded their curriculum including new subjects, purchased new equipment for their laboratories and accepted only freshmen who had completed a two-year preparatory course of study. As a result they made big strides since the time of the Flexner Report, in 1910, so that  the training of American Orthodox physicians could be described as homogeneous and highly qualified by the end of the 1920s.1:87

For various reasons, osteopathic schools were unable to keep up with orthodox institutions. Although the school directors strived to improve the quality of their courses, the lack of grants, funding and tax breaks prevented them from raising the admission criteria. Although in 1920 the AOA stipulated that schools should require freshmen to have a high school diploma, not all institutions adhered to these standards until the 1930s.1:90

Moreover, osteopaths did not all think alike. For example, Dr. George Laughlin – A.T. Still‘s son-in-law and Dean of Kirksville College – considered the attempt of osteopathy schools to mimic orthodox medical schools by introducing mandatory propaedeutic studies a mistake, arguing that this would discourage less privileged students from rural regions and small towns, with a consequent decline of physicians in sparsely populated areas.1:90-91

The internal debate on the study of pharmacology also continued: in 1920 the AOA approved a standardized curriculum containing ‘all the subjects necessary to educate a thoroughly competent general osteopathic practitioner.’ excluding pharmacology, or materia medica. However, osteopaths were getting lower scores than MDs on state exams because of the gaps in their preparation. College directors often sought compromise solutions, but had to act cautiously so as not to risk losing their accreditation with the ACO. In 1924, the Chicago college proposed to include an in-depth course on the subject of medicine in the curriculum. The proposal was rejected by the AOA with seventeen votes against and only one in favor, forcing the school to backtrack.

The violent debate between ‘pure’ osteopaths and ‘broad’ osteopaths continued to rage, although after the first quarter century the former’s position became less and less tenable. Trenching on the position of ‘pure’ osteopathy made it difficult to fight for recognition: legislators wanted to be sure that DOs possessed the same body of knowledge as MDs’. Moreover, by rejecting the study and use of drugs, osteopaths made themselves an easy target for the accusations of the AMA, which, in 1923, flatly refused to recognize the viability of osteopathic medicine.

The rancor of the regular doctors was such that the AMA’s board of directors branded osteopathy as sectarianism, stating that DOs operated on unscientific principles. It also prohibited all its members from consulting osteopaths or supporting osteopathy in any way, under penalty of being reported for violating the code of ethics and expelled from the medical register.2

For their part, osteopathic schools made their curriculum more and more similar to that of orthodox institutions. Although they claimed that the quality of their training was equivalent to that of the MDs, the DOs did not appear to be as well prepared before the licensing committees, either becausé they were leveled on a lower rank due to less restrictive admission criteria, or because the teachers were less qualified, or because the osteopathic clinical internships consisted of an average of seven hundred hours as opposed to two thousand for their Orthodox counterparts.1:91

An exception was the anomalous situation of the state of California, where in 1919 the state licensing board had declared that from then on it would refuse to examine osteopaths. Although this position was not approved by the court, the California Osteopathic Association (COA) feared for the survival of osteopathy and decided to ask the legislator for the establishment of a separate examination board for DOs. Both the California Medical Association (CMA) and the AOA opposed the initiative, the former because it was unfavorable to the fragmentation of medicine, and the latter because it believed that projects of this magnitude should be handled on a federal scale. Despite the opposition of the two associations, the bill – the Osteopathic Initiative Act – was approved in 1922. From then on, osteopathy in California became a separate medical profession. Osteopaths decided their training in the College of Osteopathic Physicians and Surgeons (COP&S) of Los Angeles and were licensed to prescribe drugs and perform major surgery in their hospitals.3

In 1926, several posts appeared in the pages of the JAOA, claiming the importance of paying more attention to the professional qualification: many DOs thought that the title osteopath was reductive and too closely related to manipulative treatments, so they urged for it to be replaced with the title osteopathic physician, which was considered more appropriate to describe their professional practice.1:111

Meanwhile, the controversies continued over the teaching of pharmacology: both osteopathic schools and many medical specialists involved in this field were making their voices heard, believing that the AOA ban limited osteopath’s scope of practice. In 1927 the AOA attempted to compromise, requiring all colleges to include a course in “comparative therapies,” without specifying what topics it was to include. Such a trick did not impress the legislator favorably and increased the frustration within the profession.

To quell the controversy, in the summer of 1929, the AOA defined a new course, called Supplementary Therapeutics, which explicitly included the study of the use of biological and chemical agents. The course was approved and rubricated as including pharmacology. This decision was momentous and marked the abandonment of ‘pure’ osteopathy.4 To accommodate the complaints expressed by some osteopathic schools that embraced a more conservative approach, the course was made optional rather than compulsory the following year.

However, the fact remains that by then the AOA had officially adopted a strategy favorable to the homogenization of osteopathic and ortodox-medical trainings. This course of action was maintained in the years to follow and enabled American osteopaths to obtain a full and unrestricted license to practice medicine.1:82-84

  1. Gevitz N. The DOs. The Johns Hopkins University Press, Baltimora, Maryland, USA 2004:81-82.
  2. Gevitz, N. (2014). The “doctor of osteopathy”: expanding the scope of practice. Journal of Osteopathic Medicine114(3), 200-212.
  3. Crum JF. The saga of osteopathy in California. West J Med. 1975 Jan;122(1):87-90.
  4. Gevitz, N. (2009). The transformation of osteopathic medical education. Academic Medicine84(6), 701-706.).

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The spread of osteopathy in the United States

5. World War I and the Spanish flu pandemic.

The departure for the front lines of regular doctors and the successes achieved in treating influenza gave an encouraging boost to osteopathy.


4. The Flexner Report and its consequences

The scandal that exposed the poor quality of most U.S. medical schools' degree programs also involved osteopathic institutions and shaped their evolution.


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

The debate between osteopaths loyal to tradition and those open to collaboration with orthodox medicine shaped the progress of osteopathy in the United States.


2. The establishment of the American Osteopathic Association (AOA)

The creation of a single registry that held annual conferences and published a monthly newsletter was a key step in the growth of American osteopathy.


1. The first years after the foundation of the ASO and the first legal recognitions

The sensational success of the Kirksville School contributed to the development of osteopathy and to the winning of regulation laws in some American states.