A.T. Still and Osteopathy

It’s National Osteopathic Medicine Week so what better time to dive into my own background.  I, as a real, living, breathing Doctor of Osteopathy, will regale you with a history of my profession in medicine.  This is something that has been a topic of particular interest to me and I’ve teased covering it for awhile.  I will admit that I actually had no idea it was National Osteopathic Medicine Week and discovered that purely by coincidence while researching this show topic.  That may show you how hardcore of an osteopath I really am. 


It’s fairly likely that many of our listeners may have been treated by a DO (doctor of osteopathy) at one point or another in their lives.  My experience has been that patients usually don’t know I’m an osteopath until they squint at my badge and say the inevitable “What’s a DO?” line.  It’s always vexing because I have to try and summarize the history of my wing of this profession in a soundbite while providing reassurance that I am, in fact, a real doctor and everything.  I don’t imagine this happens to you guys.

Though DOs are interchangeable with MD’s in all but title–you’ll find them doing family practice, internal medicine, and neurosurgery among all the other specialties–there is historic precedent behind the distinction of the title.  DOs historically have wanted to maintain their DO-ness even as it’s been increasingly difficult to say what that distinctiveness is as we’ll find out.

The DO difference all begins in response to a medical tragedy in 1864.  A man named Andrew Taylor Still had lost his entire close family to meningitis.  In that year his wife, three daughters, and one adopted child all succumbed to this bacterial infection of the brain.  People respond in all sorts of unique and interesting ways after epic tragedies, and A.T. Still decided to re-think the principles of medicine as a result.  

This was at a time of bloodletting and leeches and “heroic medicine”.  This was a time when doctors were supposed to do something and not “just stand there.”  So they did things–ALL the things–to treat patients even when those things didn’t help.  Bloodletting and leeches will not cure bacterial meningitis and A.T. Still was understandably frustrated by this.  He thinks, “there must be a better way!” and the seeds of osteopathy were born.

Let’s dive a bit into A.T. Still’s medical background.  According to my research as well as my recollections from learning a bit of this history in medical school, A.T. Still did not have a formal medical degree so far as anyone can tell.  In that time (again the 19th century), in the U.S. a person practicing medicine without a formal degree was not all that uncommon and was a problem we’ll talk about a bit later here.  

AT Still appears to have apprenticed to some degree under his father who was apparently a physician.  After spending some time with his dad he entered into service in the Civil War with company F out of Missouri, on the side of the union.  He was a hospital steward it would seem and would later describe himself as a “de facto” surgeon.  In other words he was pretty much a surgeon by Civil War standards, just minus all the formal training and stuff so that should inspire confidence.  Nevertheless it was not uncommon for hospital stewards in the Army to be promoted to roles like surgeon, especially given the awful circumstances in the medical encampments during that war.  Stewards often functioned as pharmacists and all manner of general medical staff at that time.

After the war is when his family dies and he begins to devote himself to medical complementary areas of study.  Notably he was an avid anatomist and articles describe him as being a meticulous dissector person.  Indeed, anatomy is emphasized as a foundation of osteopathic training because, as we’ll see, it’s at the root of many osteopathic principles of treatment.

It should be noted that AT Still did seek out further medical education.  He completed what was described as “a short course in medicine” at the then new College of Physicians and Surgeons in Kansas City, MO in 1870.  I’d like to imagine this was a correspondence course or something to that effect.  I’m not really sure how short the course was or what was covered, but I believe this is the last formal medical training he seemed to receive prior to founding osteopathy.

In 1874, the very same year that had many exciting historical developments such as the 1st zoo opening in Philadelphia, Hary S. Parmalee patenting the sprinkler head, and the formation of the World Postal Union in Bern, Switzerland (finally, right?), A.T. Still “flung to the breeze the banner of Osteopathy.”  I feel compelled to use those words which come from his autobiography partly because who can refuse such poetic grandiosity.  I guess it sounds better than “I made up a new kind of medicine in response to a personal tragedy.”  

What is osteopathy exactly?  Etymology nerds will note that the word means “bone pain/suffering,” more or less–osteo is bone, pathos is a bad thing.  AT Still’s basic tenets of osteopathy included the following:

1. The body is an integrated unit of mind, body, and spirit.
2. The body has an inherent ability to heal itself.
3. Structure and function are reciprocally interrelated (in other words the anatomy/MSK system and the physiological functions of the body are dependent on one another).
4. Rational therapy is based on consideration of the first three principles.  (Kinda phoning it in on that one.  I feel like this would be implied and he just wanted a longer list, maybe?)

What this meant in the context of osteopathy as a new way to do medicine was the belief that the musculoskeletal system is the foundation of health and that proper functioning and diagnosis thereof is the key to treating disease.  If the MSK system is out of wack, anatomically speaking, so too will other body systems malfunction–and vice versa, that if a problem arises within the intestines, one might find evidence of this is the MSK system and soft tissues.  I’ll pause to let that wash over my MD colleagues here.  Maybe I should add that AT Still, around the time of banner flinging, was really into spiritualism.  

Practically speaking, in the beginning, osteopathy was a purely manual manipulation type of practice.  AT Still believed that an in-depth exam of the patient’s spine and other joints might give insight into whatever medical maladies they might have.  Also, by manipulating the spine and other joints and soft tissues into a more normal alignment, one would improve the overall health of the patient.  When the MSK and soft tissues are pathological or seemingly communicating an underlying pathology, this is referred to as “somatic dysfunction.”  By the same stretch of the imagination, one could also do an exam of the MSK and soft tissues to find out what is happening with the internal organs.  In the early days of osteopathy, this focus on manual medicine, so-to-speak, also meant traditional medications were eschewed.  Granted, mercury containing calomel, arsenic, and the piles of opium that were typically prescribed around the end of the 19th century did not save people from things like bacterial meningitis, but I don’t think a good alignment of one’s spine and joints would either.

Over time–extending into the present day–osteopathic manipulative medicine (OMM) evolved several general types of diagnosis and treatment.  In osteopathic medical school, we as students had all of the normal medical school classes–anatomy, physiology, pharmacology, pathology, etc.--but in addition would have a 4-hour class every week in OMM principles and treatment, many of which derive from the writings and teachings of AT Still and his subsequent early osteopathic disciples. I won’t say that my views on the matter speak for all DOs, but when people ask me to describe what OMM is, I like to say it’s a spectrum of things that may have some semblance of physiologic plausibility to the embarrassingly pseudoscientific nonsense that should be called for what it is.  Though manipulative medicine was once the only thing osteopaths did as medical intervention, we’ll see that over time this has come to be a very small part of DO practice in the modern day. 

On the possibly reasonable side of the spectrum would be “muscle energy” techniques.  In the simplest sense this involves taking a joint to a position of restricted movement, having the person contract the muscles that move the joint against resistance, allowing a period of relaxation, and then stretching the joint to move further than it did beforehand.  The process is repeated and the goal is to see increased movement and decreased discomfort in the area in question.  Aside from the hokey name, this type of thing is performed by physical therapists as well as DOs.  This is the one and only thing I ever use on myself, typically to get a good stretch before playing hockey.

Towards the middle of the spectrum would be things like HVLA treatment.  This is where a person is positioned in a variety of ways to try and take a spinal segment (though it can be used on other joints) into a position of restricted movement and a short thrust is made to move the segment a small distance at a quick pace. This often gets a little crack out of the joint and the underlying malady is cured.  If this makes you think of a visit to the chiropractor’s office you’re not far off as there is a lot of overlap in what osteopathic and chiropractic techniques seem to look like.  This is perhaps because D.D. Palmer, the so-called father of chiropractic medicine, wrote about taking a course in osteopathic medicine in 1899 so I can’t help but think these two bits are related.  There will be many in the DO world that might take issue with that, but I would say it’s my opinion that there is not much sunlight between HVLA treatment and chiropractic treatment.  In practice DO’s, including myself of course, are taught a system of pressing on the spine and surrounding soft tissues to see if a vertebral segment seemed to be rotated oddly or bent strangely and try to put it back into its proper place.  I put this in the middle of my spectrum of plausibility because there is at least some research to suggest OMM may help with specific low back pain patients.  

At the far end of the insanity spectrum is cranial osteopathy.  This was where I, and many of my DO med school friends had a career choice existential crisis.  I recall sitting in a vast lecture hall–the same one that held amazing lectures on neuroanatomy, microbiology, and pathology–and being presented with the principles of cranial osteopathy.  Developed in the 1930s by Dr. William Garner Sutherland (DO of course), the tenets of cranial osteopathy hold that contrary to all known anatomical knowledge, the bones of the skull which fuse together in early childhood, around the age of two, are actually capable of movement.  There is the belief that there is an underlying Cranial Rhythmic Impulse that can be felt 8-14 times per minute as the cerebrospinal fluid surrounding the brain pulses to and fro.  By feeling the amplitude and rate of this CRI, one skilled in cranial osteopathy can diagnose underlying pathology or try to treat it by restoring the pulse to normal.  I was sitting in class while this was being described and I, as a staunch skeptic then and to this day, was horrified.  It will not surprise you to find out that despite many, many, many efforts to prove the concept, the CRI has not been demonstrated to exist and skull bones do not move to any perceptible degree.  Many prominent DOs have spoken out or written about the need for osteopathy to stop teaching this.  I share that opinion as you might imagine because this is absolutely bunk and does not belong in a medical school curriculum outside of mention as a historical part of the profession that was, medically speaking, complete nonsense.  Myself and several friends and colleagues actually refused to participate in practice of this during our OMM classes towards the end of medical school. 

With those principles in mind, we’ll return to the story of how DOs gradually became respected members of the medical profession.  

From the founding of the American School of Osteopathy in Kirksville, MO by AT Still himself in 1892 until the 1950’s or so, DO medical practice was purely OMM treatments.  DO schools did not start teaching the principles of pharmacology at all until 1929, over ten years after the death of A.T. Still in 1917.  I’m not sure he would have liked that.  

In the early 20th century, however, DOs started to adopt more and more principles of traditional MD medical training and the profession moved to legitimize itself in the house of medicine.  This was a long, uphill battle for the better part of the last 100 years.  The first test was, fittingly, passed by the DO schools themselves.  I mentioned the problem of the whole “how to be a doctor” thing being too unregulated earlier.  This was a major problem in the US in the early 20th century.  To codify and improve medical education, something called the Flexner report was released and it called for a systematic way to vet and credential medical schools and the education of physicians in general.  Though the DO schools of the time did not teach a curriculum identical to their MD counterparts, they did have rigorous study of anatomy and physiology and, with some adjustments, were able to survive the fallout from the Flexner report.  To put it into perspective, there were 155 medical schools in the US in 1910 at the time of the report’s release.  After the report, 31 schools remained standing and able to graduate doctors.  Many of the early DO schools were among them and are still in operation to this day.  This was a big step towards legitimizing DOs in medicine.  

In the 1950’s, osteopathic practice started to incorporate more concepts of what we’d call primary care.  Many DOs went into family practice while still doing manipulative medicine.  Though pharmacology was regularly taught in DO schools for the prior 20 years, there were some interesting growing pains.  While I was in medical school, one of my neighbors was a long-retired DO who graduated in 1955.  He took my wife and I out to dinner once and told us a bunch of amazing stories, including the fact that in the 50’s, where he practiced, he would have to contract with an MD to sign his prescriptions to make them official.  Different times to be sure.  

It was in the 1940’s and 1950’s that DOs found themselves butting heads with MDs and the American Medical Association in general.  As recently as 1961, the AMA code of ethics had declared it “unethical for a medical physician to voluntarily associate with an osteopath”.  Prominent MDs in the AMA wrote about DOs in rather unflattering terms.  In 1954, osteopathy was described as “cultish” in a paper by Dr. Charles L. Farrell, M.D. who opposed cooperation between MDs and DOs.  He, and many others, pointed to what they deemed to be pseudoscientific practices within OMM and what appeared to be staunch adherence to A.T. Still’s principles of medicine despite evidence to the contrary.  Farrell’s objections included a citing from a 1952 osteopathic textbook which stated “A.T. Still’s discoveries have been ‘progressively confirmed’ and ‘never invalidated.’  To that effect I can empathize with where these MDs were coming from in this regard.  

From 1916 to 1966 osteopaths were in a “long and tortuous struggle” to serve as physicians and surgeons in the military as one article put it.  DOs were not allowed to have practice rights in the US military during WWI and WWII.  This changed when on May 3rd, 1966, Secretary of Defense Rob McNamara authorized DOs to be accepted into all military branches on equal practice basis as MDs.  This was a big step for the DO profession.  

As DOs were practicing more traditional medicine, what with all the pharmacology and stuff, there were a few more hiccups with the AMA in the 1960’s.  A notable example took place in California in the 1960’s where not much else was going on, historically speaking.  

The AMA, at that time, spent $8 million dollars to stop osteopathy in the state.  Proposition 22, a statewide ballot initiative, barred DOs from practicing in California.  The California Medical Association offered to issue DOs an MD degree if they payed a $65 fee and took a “short seminar” to bestow them with MD-ness, I guess.  86% of the DOs at the time in California took them up on the offer.  I don’t know how much of that was due to needing it to practice medicine at all in CA at the time, or how much was a rebuke to keeping the DO degree and identity separate.  The AMA re-accredited the University of California at Irvine College of Osteopathic Medicine as University of California, Irvine School of Medicine (MD School) and banned the issuing of MD licenses to DOs moving to Cali from out of state.  This all stood until 1974 when protests and lobbying of the California supreme court by prominent DOs allowed osteopathic licensing to resume in the state.  As an aside, the DO degree was not uniformly recognized in all US states until 1973.

By 1969, the professional rift between DOs and MDs starts to mend.  That year, it was approved that DOs can be part of the AMA and DOs were also allowed to participate in MD residencies–not allowed before this.  Interestingly, the American Osteopathic Association (our AMA, if you will) rejected the measure to let DOs go to MD residencies.  There were efforts then, and some still now, to keep the DO degree and approach to medicine as a whole, as a separate and distinct identity.  At the time I attended and graduated from residency, I had to make a choice whether to apply to DO residiencies or MD residiencies, opting for the latter.  I had to take two sets of boards (MD vs DO boards are different) and many of my compatriots had to make similar choices.  In 2014, however, the AMA and AOA merged the residency process removing the distinction.  I see this as a very good thing, personally.  

With that gradual evolution, the DOs of today are interchangeable with MDs in all other aspects.  Several of my classmates are in all the fields and hypersubspecialties of medicine.  This has led to an interesting question of what, in the modern era, makes the DO degree and DO physicians all that different.  According to a study from the Journal of Osteopathic Medicine done in 2021, the data suggests the use of osteopathic manipulative medicine in practice is declining.  This was definitely the case when I was in school, too. Of 10,000 surveyed DOs in that study, only 16% responded and of those, ¾’s of themused OMM on less than 5% of their patients and just over half did not use OMM at all.  So if DOs are not practicing OMM much at all in the real world, what is the distinction of the DO profession at this point.  Why have a separate degree at all?  I do have strong opinions on the matter but this is a history show so I’ll spare them–I suspect many listeners might guess what I think.    

I should also mention that osteopathy and the practice thereof as a medical provider may look very different in other countries.  While D.O.’s may have full practice and prescribing rights in the U.S., Canada, and many, many other countries, some countries do not allow DO’s to practice in such ways–France as an example.  In this regard, DOs can only practice manipulative medicine and not prescribe.  

My final thought, and the reason I wanted to do a show on the history of my own degree, is to leave you all out there with a positive impression.  The historical origins of the degree are certainly interesting and worth remembering, but many of the pseudoscientific concepts that may have been taught–or might still be taught–in the world of OMM are far from defining features of osteopathic training.  DOs are in every area of medicine doing incredible work.  DOs have been surgeon generals and are every bit as capable as our MD colleagues.  So if you notice your doctor is a DO on your next visit, perhaps you’ll know a little more about why initials following their name are just a bit different.  In the end, a good doctor is a good doctor.

Sources:
https://books.google.com/books?id=H08EAAAAMBAJ&q=andrew+taylor+still+lightning+bone+setter&pg=PA108#v=snippet&q=andrew%20taylor%20still%20lightning%20bone%20setter&f=false (Life article about AT Still)
https://quackwatch.org/chiropractic/rb/bcc/8-2/ (Farrell comments on osteopathy)
https://pubmed.ncbi.nlm.nih.gov/22331804/ (DOs not able to serve in WWI and WWII as docs).
https://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_United_States#History (General overview)
https://en.wikipedia.org/wiki/Andrew_Taylor_Still (AT Still’s life overview)
https://www.amboss.com/us/knowledge/Cranial_osteopathy/ (Cranial stuff)
https://bmjopen.bmj.com/content/12/4/e053468 (Summary of research on OMT)
https://pubmed.ncbi.nlm.nih.gov/33512391/ (OMT use in US nowadays)
https://www.aacom.org/become-a-doctor/about-osteopathic-medicine/history-of-ome (timeline of notable DO historical events)

Max

Doctor with a mustache.