Special Communication  |   March 2014
The “Doctor of Osteopathy”: Expanding the Scope of Practice
Author Notes
  • Address correspondence to Norman Gevitz, PhD, Senior Vice President, Academic Affairs, A.T. Still University, 800 W Jefferson St, Kirksville, MO 63501-1443. E-mail:  
Article Information
Being a DO
Special Communication   |   March 2014
The “Doctor of Osteopathy”: Expanding the Scope of Practice
The Journal of the American Osteopathic Association, March 2014, Vol. 114, 200-212. doi:10.7556/jaoa.2014.038
The Journal of the American Osteopathic Association, March 2014, Vol. 114, 200-212. doi:10.7556/jaoa.2014.038

This article—the third in a 6-part series—examines the status of the DO degree in the first 3 decades of the 20th century. This time was an era when osteopathic practitioners established other colleges, developed state and national organizations, upgraded the length and breadth of curricula, and sought to secure licensure laws commensurate with their expanded education. During this period, osteopathic practitioners debated whether the DO degree was the most appropriate degree for their colleges to award or whether the MD degree alone or in conjunction with the DO degree better signified to lawmakers and the public their expanded academic training. At the end of this period it appeared likely that the DO degree would continue to be the sole designation by which osteopathic physicians would identify themselves in continuing their fight to obtain further legal rights and privileges.

Before the end of the 19th century, Andrew Taylor Still reconciled himself to the idea that his discovery was best represented to legislators, the public, and its advocates not as a new “science of health” but as a new “school of medicine.” Though he strongly believed that the terms drugs and medicine were interchangeable, his advisers convinced him that the word medicine had a far broader meaning and encompassed all knowledge pertaining to health and disease. Having obtained Still's half-hearted blessing, osteopathic advocates began to make a more forceful case for obtaining equivalent legal recognition of Still's system with other contemporary “schools of medicine”—homeopathy, eclecticism, physio-medicalism, and of course, orthodox medicine, which its critics invariably called allopathy.1-4 
This revised conceptualization of osteopathy as a “school of medicine” led some followers to the logical deduction that as a branch of medicine, all osteopathic graduates should be awarded an MD degree, which universally signified a “Doctor of Medicine.” Indeed, other recognized “schools of medicine”—despite their significant differences in therapeutics—were bestowing this traditional designation. This argument was forcefully taken up and championed by J. Martin Littlejohn, dean of the American School of Osteopathy (ASO), who along with his faculty petitioned the school's Board of Trustees in 1899 to change the degree awarded from DO to MD (Osteopathic).5,6 Still summarily dismissed this proposal on the basis of his unshakeable belief that his system was radically different than all other “schools of medicine.” He maintained that the MDs, despite their therapeutic differences, were all “drug doctors,” and in signifying his graduates as DOs, Still could assure members of the public that in seeking out osteopaths, they would never fall victim to the curses of drug toxicity, addiction, or drunkenness. For him and most of his followers, the DO degree stood as a powerful symbol of the vast therapeutic separation between osteopaths and all other medical practitioners.7 
Still, however, made a significant concession to critics of his chosen diploma. For the ASO graduating class of June 1900, he agreed to formally alter the title of the degree from “Diplomate of Osteopathy” to “Doctor of Osteopathy.” Many osteopaths argued that this change in language was necessary to convey the impression to the public that the recipient of this diploma was of professional standing—a doctor—and not an unlettered mechanic. Nevertheless, to the frustration of some supporters, Still continued to use the term diplomate and persisted in comparing DOs to a host of different manual tradesmen such as plumbers, carpenters, and electricians.8,9 
Legitimizing the DO Degree
Upon graduation, most DOs went back home to begin practice. Some, however, preferred a fresh start. Several wealthy and well-connected clinic patients who were enthusiastic about the care they received made offers to soon-to-be graduates to accompany them to where they lived; they promised to introduce the graduates to their friends and acquaintances and provide ready testimonials to the merits of osteopathy. The success of these newly minted DOs in establishing a successful practice depended not only on their ability to attract patients and relieve their health problems but also on their capacity to curry favor with local MDs, as well as prosecutors, judges, and juries in those states where laws had not yet been passed permitting osteopathic practice.1 
In 1895, Vermont became the first state to recognize the practice of osteopathy within its borders. However, nationally it was tough going. Vermont was followed by North Dakota (1897), Missouri (1897), Michigan (1897), Iowa (1898), South Dakota (1899), Illinois (1899), Tennessee (1899), Montana (1901), Kansas (1901), California (1901), Indiana (1901), Nebraska (1901), Wisconsin (1901), and Connecticut (1901).1,10 The relatively ragged pace of legislative enactments across the country was a result of not only the opposition and effective lobbying by state medical societies but also the internal divisions within the osteopathic ranks over such issues as what should be the minimum educational requirements for licensure, whether candidates should be subject to an examination, and whether DOs should be granted their own independent regulatory boards.1,10,11 
Some of this disarray within the larger osteopathic community can be attributed to the emergence of other osteopathic colleges, each operating under varying interpretations of what osteopathy was and how it should be taught. At least 28 of these schools (likely more) were incorporated between 1895 and 1903—4 apiece in Missouri, Illinois, and California; 3 in Iowa; 2 apiece in Pennsylvania and Kansas; and 1 each in Colorado, Massachusetts, Minnesota, Wisconsin, North Dakota, Kentucky, New York, Ohio, and Rhode Island.1,10 
Still had nothing but disdain for these schools. He was incredulous at the presumptiveness of his graduates who thought that after 2 years (or less) of osteopathic education, they had anywhere near the sufficient background or experience to teach a science that he had spent decades in the field perfecting. Even worse, some of these schools were founded by individuals who had not even attended the ASO. Although several of these colleges placed themselves on a solid educational foundation, many more did not. Some schools promised to graduate DOs in less time than the ASO, and given their meager educational expenses, they were able to charge a far lower tuition. Still fumed that many students who would otherwise matriculate at his school were being hoodwinked into attending inferior colleges whose cut-throat business practices threatened his institution's ability to compete and to even survive.1,10,12 
The earliest rival college—the National School of Osteopathy—was established in 1895 in Kansas City, Missouri, by Elmer D. Barber, who along with his wife, Helen, were graduates of the ASO's second class. In 1897, Missouri passed an osteopathic act, which required 2 years of classroom attendance for licensure. Soon after the law went into effect, word filtered back to Kirksville that Barber was illegally shortening the requirement for some students and that he may have been engaged in selling diplomas. William Smith, the ASO's first anatomy professor and a graduate of the first class, had never met the couple, and so he was asked to go to Kansas City to set a trap for Barber. Making an appointment under an assumed name, Smith convinced Barber that he was well versed in osteopathy but didn't want to spend any time in school and that he was just desirous of possessing a diploma so he could legally practice in the state. Barber offered to provide him with one for a $150 cash payment. After receiving the diploma, Smith proceeded to the office of the attorney general, who indicted the Barbers. Although the couple was found guilty of violating the new law and fined, the court did not find the offense serious enough to vacate their college's charter. Their institution finally closed in 1900 after Barber was again charged with fraud. During its existence, the National School of Osteopathy bestowed diplomas on at least 50 individuals, some of whom founded other academically dubious osteopathic colleges.1 
Still was particularly outraged by Barber's writings. Fresh from graduation at the ASO, Barber put together a manuscript based on the extensive notes he had taken at Still's infirmary. Published in 1896, it became the first available treatise on the new science. In his preface, Barber declared that Still wanted to keep the practice of osteopathy a secret, and so it was left to him to reveal “its grandeur, simplicity, and truth.”13 
In seeking to reach a general audience, Barber employed a straightforward approach by avoiding anatomical words and medical phrases that he declared have been used to confuse and mystify people. His goal went beyond explaining osteopathy to the masses. He stead-fastly maintained that laypersons with no formal training could use his well-illustrated book to learn how they could treat themselves, their families, and others. In 1898 Barber published another book—essentially an enlarged version of his first work under a different title.14 
Although Barber gave Still due credit as the founder of osteopathy in his first book, he pointedly declared that the original theory that “nearly all diseases are caused by dislocated bones”13(p11) was incorrect. Barber argued that he and his wife had found very few “dislocations” in their practice, and he believed instead that what Still and other osteopaths were finding in their examinations and successfully treating were “contracted muscles,” thus making osteopathy appear to be a form of massage.13 In his second book, Barber declared that apart from originating the name osteopathy, Still had not discovered anything new in anatomy, physiology, or treatment that had not been observed and written upon by earlier medical writers.14 
Barber proved to be a persistent troublemaker. Upon closing his college in Kansas City he relocated in Chicago, where he opened a “correspondence school” that provided lessons on osteopathy through the mail and a handsome “Doctor of Osteopathy” diploma on completion of the assignments.15 Barber, however, was not alone. One osteopathic leader estimated that 30 correspondence schools were in business in Chicago and elsewhere at the turn of the 20th century.16,17 
These educational entrepreneurs did considerable damage to the professional reputation of osteopathy. State medical societies used Barber's books as evidence of the fraudulent nature of osteopathic practice. In some states in which formally educated DOs had convinced legislators to support osteopathic bills with strict educational qualifications for licensure, other self-proclaimed osteopathic practitioners with no formal classroom training worked furiously and sometimes effectively against the passage of these bills if they did not contain a “grandfather” provision that would guarantee them the legal right to continue their practice (even though they were bereft of acceptable credentials).1 
As the number of osteopathic schools and practitioners of all grades mushroomed, ASO students, faculty, and graduates concluded that for the profession to survive, they and those osteopaths from other reputable colleges needed to organize to forward their interests. In 1897, they established the American Association for the Advancement of Osteopathy (AAAO)—a membership society composed of practitioners and students. The following year, the more highly regarded schools joined together to form the Associated Colleges of Osteopathy (ACO).18-20 
In 1901, the AAAO reconfigured itself with a new constitution and a new name—the American Osteopathic Association (AOA).21 The AOA sought to uplift educational standards, adopt a code of ethics, aid legislative efforts to secure osteopathic licensure, improve public understanding of this new school of medicine, launch scientific research efforts to prove osteopathy's value, and shut down the correspondence schools and eliminate fakirs and imitators, who were despoiling the field for legitimate osteopaths.1 
The AOA required each of the colleges to lengthen its curriculum from 2 years (20 months) to 3 years (27 months) by 1904. With this educational upgrade, the AOA and state societies intensified their efforts to obtain legal recognition. By 1913, 39 states and territories had passed osteopathic practice acts. As a consequence, those with correspondence school diplomas found it more difficult to legally practice, and in turn many of these businesses, unable to deliver on their promises to students, closed their doors.1,10 
Their success on the legislative front was tempered, however, by their inability to stop the progress of 1 particular imitator. Chiropractic, founded by Daniel Palmer and effectively led by his son B.J., offered students a cheaper and far shorter curriculum of earning a degree—the Doctor of Chiropractic (DC)—to practice a rudimentary form of spinal manipulation. After 1900, this rival movement gained a popular following, and in 1913, Arkansas became the first state to provide a path to licensure for these practitioners. The rapid growth and increasing legitimation of chiropractic was both a cause and a consequence of some osteopathic physicians' efforts to expand the length of the college curriculum and increase their scope of practice.1 
The “MD, DO” and the “DO, MD”
Two persistent questions vexed the leading academic lights at the ASO and other osteopathic colleges: What subjects should be included in the school curriculum, and what should be their graduates' scope of practice? When he established the ASO, Still began by offering a narrow curriculum embracing only palpatory diagnosis and manipulative treatment. Nevertheless, there is compelling evidence in his 1892 charter and first professorial appointments that he wanted to incorporate coursework in minor surgery and obstetrics at some point. In 1897, he at last announced that he would do so, and as part of the training in these subjects, ASO students would hence-forth receive instruction in the properties and uses of anesthetics, antiseptics, and antidotes.1 He later used the term osteopathic materia medica to refer to these approved pharmaceuticals.22 With his new curriculum in place, Still declared that osteopaths would now be trained to become general practitioners who could handle both acute and chronic diseases, set broken bones, stitch and dress wounds, and deliver babies. 
This curricular evolution did not sit well with many earlier ASO and other osteopathic college graduates who had not been given this training. Those individuals who believed the old way was the right way soon identified themselves and other like-minded practitioners as “lesion osteopaths.” They were content restricting themselves to finding the lesion, fixing it, and leaving it alone. They argued that in the rare instances that surgery was necessary, they would refer their patients to experienced MDs in that field, preferably those who had abandoned “drugging,” entered osteopathic schools, and had now become “MD, DOs.”1 
Dozens of MDs enrolled in the ASO and other schools, convinced that osteopathy offered them something new and better in treating their patients. Some of these MD, DOs had a complete conversion experience and practiced what they considered to be a “pure” osteopathy.23-25 Others became general practitioners incorporating osteopathy, surgery, and obstetrics and using the range of drugs Still sanctioned. But several MD, DOs thought Still's osteopathic materia medica was far too limiting. They noted that the polypharmacy that was so rampant in the day when Still practiced medicine was disappearing. Many of these MD, DOs saw no reason why they should not incorporate any diagnostic, preventive, or therapeutic modality that appeared to them to be of value. They and other DOs who thought similarly identified themselves as “broad osteopaths.”1,26,27 
The other and eventually more numerous dual-degreed osteopathic contingent was the “DO, MDs.” Some of Still's early graduates complained that the length and breadth of the curriculum was inadequate compared with what was offered by either 3- or 4-year medical schools. They bemoaned the fact that in osteopathic school there were few opportunities for dissection, little microscopic work, and inadequate opportunities to learn surgery, learn how to deliver babies, and gain meaningful hospital-based experiences either in wards or in outpatient departments. Most DOs who entered medical schools sought not only additional knowledge and skills but also the professional status that came with being an MD—especially the ability to secure full licensure privileges, which only possessors of that degree could then universally obtain. Many believed that by virtue of being dual-degreed, they would be able to raise the status of the osteopathic profession and better convince the public that they had the breadth and depth of education, experience, and access to the means necessary to successfully handle any health condition or emergency.28,29 
Among the first of the DO, MDs was Marcus L. Ward, who in the 1880s had initially come to see Still as a patient. After he successfully treated Ward, Still took him on as an apprentice. Later, Ward became a share-holder and the vice president of the ASO under the first charter. After receiving his diploma, he relocated to Ohio, enrolled in the Medical Department of the University of Cincinnati, and in 1897, upon obtaining his MD degree, moved back to Kirksville and opened the Columbian School of Osteopathy on the other side of town.1 
Ward called himself the re-discoverer of “true osteopathy”—a system of surgery, medicine, and manipulation, which he said was developed by the ancient Greeks. His college offered students the opportunity to study all the healing arts. After the first 2 years, students would be awarded a DO degree, but if they stayed for an additional year, they would obtain further medical and surgical training and on completion of the course would be graduated with an MD diploma.1 In writing of Kirksville as well as Ward and his associates, Still acidly noted, “Every man and woman sick and tired of drugs, opiates, stimulants, laxatives and purgatives has turned with longing eyes to this Rainbow of hope…and yet these medical osteopaths are trying to paint this rainbow with calomel and perfume it with whiskey.”30(p167) He ranted that Ward's college was a “mongrel institution” and that any student who enrolls “gets neither medicine nor osteopathy, but a smattering, enough to make a first class quack.”30(p166) Although Ward's Columbian School attracted many matriculants during its first 2 years of operation, he and his backers had a falling out and the institution, much to Still's great relief, closed in 1901 after having awarded as many as 70 diplomas.1 
1 Degree or 2 Degrees
The implementation of the 3-year osteopathic curriculum required colleges to increase their institutional resources. Many weaker members of the ACO found they could not meet these conditions and so voluntarily closed their doors. School location was another significant determinant in whether a college survived. With the sole exception of the Kirksville school, which was a magnet for attracting students nationally, each of the ongoing colleges had been established in a sizable metropolis where it could more easily secure matriculants and a sufficient number of clinic patients. Kansas City, Des Moines, Chicago, Philadelphia, and Boston were each locales for a single school and Los Angeles was home to 2 colleges.1,10 
As the 3-year course did not fulfill all their expectations in producing osteopathic general practitioners, some college leaders considered whether to add an elective or even mandatory fourth year to the curriculum. This additional coursework would strengthen student training in surgery and obstetrics and hopefully would allow students to practice these fields after graduation. However, college administrators were unsure whether they could secure the needed legislation across the country. Many legislators, on the basis of earlier osteopathic representations of their system, viewed DOs as “drugless healers,” and they believed it would be difficult now to get them to change their minds. On the other hand, they privately thought that lawmakers might be more receptive to granting osteopaths an unlimited scope of practice if their schools awarded MD degrees, which would signify to them as well as their constituents that their 4-year graduates were, in fact, physicians and surgeons.1 
In 1909, the presidents of 3 osteopathic schools went public and announced that it was their intention to use this opportunity of lengthening the curriculum to award the MD degree. If there was a voluntary fourth year, why not, as the Boston school planned, give the DO degree after 3 years and then the MD degree after the fourth.31 If there was a mandatory fourth year, why not, as the Pacific College in Los Angeles announced, give a new combined degree of “DO, MD.”32,33 Although the Chicago school supported the Pacific College's proposal, its president, Littlejohn, had already gone on record opposing the awarding of the DO degree altogether.5,6 
The plans of these colleges became known to the osteopathic community just prior to the beginning of the annual AOA convention, held in Minneapolis in August 1909. It soon became clear to the proponents that the vast majority of the attendees in Minneapolis were bitterly opposed to awarding the MD degree. On the first day of the convention, after C.W. Young made an impassioned defense of the distinctive DO degree and questioned the motives of the administrators of the 3 schools, Martin W. Peck, representing the Massachusetts College of Osteopathy (MCO), addressed the criticism.31 He declared that there were 4 good reasons why his college's board of trustees was in favor of awarding the MD to future students who complete the fourth year. First, he observed, many students and graduates desire the MD degree but are unwilling to complete 7 years of education (3 in an osteopathic school and 4 in a medical school) to obtain both diplomas. Second, he noted, the MCO had many English and Canadian students and in these countries only the MD degree would provide them with legal standing in their homeland. Third, the MD degree “would clear up to a large measure all the legal difficulties that we are now experiencing all over the country.”31(p28) And fourth, he argued, “there is in the association in the minds of all people of the physician and doctor with the MD and this association is fixed and immovable.” The day's session ended shortly after Peck's presentation, and general discussion continued the following day.31(p28),34,35 
On the third day of the convention, after the conclusion of a presentation on the treatment of patients with hip joint disease, C.M.T. Hulett, chairman of the AOA Board of Trustees, unexpectedly rose from his seat and asked for recognition. Ten years earlier, he had taken the lead in opposing Littlejohn in his effort to have the ASO award the MD degree, and now he was once again ready to do battle with his successor as ASO dean as well as with the other college representatives.36 Hulett offered a resolution, which declared that the AOA…

…deplores the radical and dangerous departure from the ideals of the profession…to grant the MD degree. We give it as our conviction that such a course will lead to inevitable professional suicide, since State Medical Boards would refuse recognition of the title thus obtained, and our profession would as certainly withhold support.

Hulett then put teeth into his resolution.

So strongly are we impressed with the dangers involved that we recommend to the [AOA] Committee on Education and Board of Trustees that no college which grants the degree of Doctor of Medicine shall be elected or continued as a co-operating organization.

Hulett then moved for the immediate adoption of his resolution, and it was seconded and quickly carried.31(p36),37 
Following this vote Louisa Burns, a faculty member of the Pacific College and one of the profession's leading researchers, formally protested, noting that all the official school representatives were then meeting elsewhere in the convention hall at an ACO open forum and arguing that it was highly inappropriate for the AOA to vote on such an important question without the other side having an opportunity to present its case. Hulett agreed to a revocation of the vote and the college representatives who were not present were invited to come to the main hall and address the audience.31 
Littlejohn, who was then serving as president of the ACO, spoke for the 3 schools. Sensing hostility by many in the audience toward his colleagues and himself, Littlejohn tried to table the resolution. He offered a substitute amendment to the effect that “the entire subject of degrees be referred to the [AOA] Committee on Education and the ACO for investigation with a view to making a complete report at the next [annual] meeting.”31,39,40 The assembly, however, was intent on registering its feelings on this issue. Littlejohn's amendment as well as one offered by Burns were both defeated, and Hulett's original resolution was again adopted by a near unanimous vote.31,41 
The representatives of the 3 colleges left Minneapolis angry at the proceedings and undeterred. C.A. Whiting, president of the Pacific School, believed that the AOA acted in a tyrannical way against the interests of the colleges. All of the college leaders believed that Hulett's resolution was not fully debated and violated procedural rules. The administrators noted further that even if it was in order, Hulett's resolution did not yet have the force of policy because it was a recommendation to both the members of the AOA Committee on Education and the AOA Board of Trustees for future action. They convinced themselves that with the passage of time their opponents might become more receptive to their plans.42 
The editor of The Journal of the American Osteopathic Association (JAOA), H.L. Chiles, would give them an opportunity to make their case by opening the pages of the JAOA to those for and against the colleges awarding an MD degree.43 In the months thereafter, Littlejohn, Peck, and Whiting laid out their arguments and defended the principle that each college should have academic autonomy to proceed as they thought best in this matter. They received scant support from the rest of the profession. All but 1 of the numerous published opinions by AOA members in the field opposed the colleges issuing any degree other than the Doctor of Osteopathy.44-47 Furthermore, other school administrators expressed dismay over the intentions of these 3 institutions. C.E. Thompson of the Des Moines College argued,

Let us rather magnify the DO forever and aye, let it stand for all which the profession stands. If we want it to stand for operative surgery, so let it stand—equip ourselves, then go to our lawmaking bodies and say: Osteopathic laws must include surgery.48(p102)

Thompson charged that those administrators who wanted their colleges to award an MD degree didn't have the fortitude to fight a prolonged battle to expand their legal privileges under their DO designation. 
As negative letters continued to be published month after month, the proponents of the MD degree eventually realized that should their schools proceed further, the AOA Board of Trustees would surely embrace Hulett's proposal and disaccredit their colleges.49,50 As the next AOA convention approached, Littlejohn conceded ground to his opponents and sought to forge a consensus in charting the way forward. “The foremost states,” he noted, “are demanding a four year curriculum, with equality of entrance requirements, equality in the course of study. This opens the way for demanding equality in right and privilege.”52(p407) Now, acknowledging that Thompson's view was the prevailing opinion in the profession, Littlejohn noted,

Let our legislative committees enter the field to establish an equality of right for the diploma of a reputable college of osteopathy and surgery, and if you wish to maintain your independent title incorporate it in the legislative enactment, and thus give it status.51(p407)

At the 1910 AOA convention, held in Los Angeles, the various sides worked hard behind the scenes to avoid fracturing the osteopathic movement. Each of the 3 colleges announced they would not go forward in awarding MD degrees.52 AOA leaders, in turn, publically reassured the advocates for the medical degree that they continued to hold them in high esteem and explained that the sometimes harsh language directed at them by some opponents was a reaction to their proposed policy and should not be taken as personal affronts. Finally, both ACO and AOA leaders spoke positively of the need to revise osteopathic licensure laws to allow graduates to practice surgery and obstetrics, and to use a limited range of drugs “as taught in the colleges.” Although many attendees at this convention believed they had successfully avoided a professional breach, they were also convinced that this debate over the degree or degrees to be awarded had not been settled with finality.53 
The Postgraduate School Degree
The “truce” between the AOA and some of the colleges did little to address the immediate needs of those DOs who wished to add greater depth and breadth to their osteopathic education or practice a broader osteopathy than current state laws allowed. In addition, some college faculty felt frustrated by what they believed to be the AOA's intrusion into their school's efforts to address their particular problems. In 1911, Peck, who had represented the MCO at the Minneapolis convention, left the college and his practice to enter Harvard Medical School, graduating in 1915 with his MD. He later became a well-published and nationally-known psychoanalyst. However, Peck's willingness to spend 4 more years in a “class A” medical school to obtain an MD degree was not the most traveled route by DOs seeking this diploma. Most DOs frequented schools not accredited by the American Medical Association (AMA) so they could receive advanced credit.54-56 
With the Pacific College having to backtrack on its plans to award a “DO, MD” degree, a West Coast entrepreneur saw an opportunity to fill a need to provide MD degrees for DOs. Frank P. Young, an MD graduate of the University of Kentucky, had taught surgery at Ward's Columbian School. When it closed, the ASO hired him to teach the subject, and there he completed the requirements for his DO degree. Young soon after published an important textbook, Surgery From an Osteopathic Standpoint (1904), and later joined the faculty of the Los Angeles College of Osteopathy.57,58 In 1912, Young incorporated a separate institution—the Pacific Medical College—and 2 years later began recruiting DOs who would be granted an MD degree if they completed additional coursework. Although the AOA and both Los Angeles colleges lamented this development, there was nothing outside of ostracizing Young that the AOA or the osteopathic schools could do.59,60 The California Medical Board, however, did act. It refused to accredit this institution, and in 1918, it exerted intense legal pressure on Young forcing him to surrender his school charter. Years afterwards, Young forfeited his medical license when it was discovered he sold postdated diplomas from his defunct school to a criminal ring who resold them to individuals with no prior osteopathic or medical education.61,62 
Other DOs considered establishing a “postgraduate” school, including a very surprising group. In March 1914, Charles Still (the founder's son and vice-president of the ASO), Summerfield Still (A.T.'s nephew), and George Still (the “old doctor's” grandnephew), along with another ASO official announced they would soon launch the Missouri Valley Medical College in Kirksville on the grounds of Ward's Columbian School. Two- and 3-year osteopathic graduates would complete the balance of 4 years of work after which they would be awarded an MD degree. The promoters claimed that they would provide matriculating DOs with additional laboratory and surgical instruction and a limited course in materia medica.63 
A.T. Still, now 86 years old, made no public comment on his son's new business venture. However, journal editors, ASO alumni societies, and members of the profession at large expressed outrage at this proposal. Critics could not comprehend why these well-known ASO administrators and stockholders wanted to establish a separate school to teach these subjects and bestow a different degree. There was no legitimate reason, they noted, why these topics could not be taught—and taught well—under osteopathic auspices in a 4-year curriculum. They argued that these ASO officials should instead be striving to make their school's curriculum as long, as deep, and as broad (except for pharmacology) as that of MD schools. If they did that, the critics observed, they would be better able to convince legislators and the public that holders of the DO degree should be licensed as “physicians and surgeons.” As a result of the avalanche of criticism, the ASO leadership group ditched their original proposal and now focused their attention to how and when they might institute a 4-year osteopathic program leading solely to the DO degree.63-65 
Adding a mandatory fourth year was fraught with potentially dire economic consequences. College administrators feared that this educational upgrade would result in a significant decline in the number of matriculants and thus produce a sizeable decline in their revenue at the same time they would need more money to implement the changes to the curriculum. Nevertheless, with more state legislatures considering the implementation of higher educational requirements, most administrators realized it was simply a matter of time before they were forced into action. By the fall of 1916, most of the schools had introduced a mandatory 4-year course of instruction leading to the DO degree.1,66 
Two schools, however, went in a different direction and eventually lost their AOA accreditation. The first was the Central College of Osteopathy located in Kansas City. In 1916, its management incorporated a postgraduate medical school—the Kansas City University of Physicians and Surgeons—to allow 2- and 3-year osteopathic graduates to get advanced credit.67-69 Local osteopaths reacted quickly to this move and in that same year launched a new 4-year osteopathic school—the Kansas City College of Osteopathy and Surgery—whose leadership pledged to adhere to AOA standards.70 The second institution was the MCO. In 1915, it began a relationship with a long extinct but recently resurrected medical school—now named the Middlesex Medical College. The 2 colleges temporarily shared the same quarters, and the MCO president, Wilfred Harris, soon encouraged his students to “complete” their education at Middlesex and obtain the MD degree. After Harris was shot dead by another member of an osteopathic love triangle, the MCO returned to the fold. However, the Middlesex Medical College eventually purchased the MCO, and the AOA disaccredited the institution.71-76 
The Sine Qua Non
As several osteopathic schools began implementing the 4-year DO degree, America mobilized for its entry into the First World War. In their desire to contribute, DOs sought inclusion in the military medical corps as commissioned officers. In 1917, AOA Past-President O.J. Snyder wrote to the Secretary of War urging him to appoint DOs and noting the special talents that DOs could provide the wounded.

Reports from the field of action show that much work following that of the surgeon, and with the many diseases following shock and trench exposures, are of such a nature as to be especially amenable to mechanical treatment, and it is to these we wish to devote our efforts.77(p2)

The Surgeon General of the Army William Gorgas, MD, was adamantly opposed to commissioning DOs. He informed the House Committee on Military Affairs that DOs should not have an equivalent standing with MDs. He gave 2 reasons: first, osteopathic practitioners did not possess the necessary length, breadth, and depth of medical education and second, the standards of osteopathic medical schools were much inferior to those of AMA-accredited medical colleges. Gorgas and his staff argued that if DOs enlisted or were inducted as common soldiers, they could request to be assigned to medically related positions as aides or technicians. They might even be allowed to employ osteopathic manipulative procedures but only when requested by commissioned MDs and only when under their direct supervision.78,79 
Months into the conflict, neither the Army nor the Navy secured a sufficient number of graduates from class A medical schools. In the meantime, the DOs persisted in their lobbying efforts to obtain military medical commissions. Despite their willingness to serve, Gorgas and his lieutenants defiantly maintained before congressional committees that having a shortage of physicians to serve American troops was far better than recruiting doctors who were poorly trained. Gorgas, however, eventually did what he said he would not do. Facing the reality of this severe shortage, he agreed to take into service MD graduates of unaccredited medical schools. This policy change prompted Henry Bunting, editor of the periodical Osteopathic Physician, to lambast Gorgas, declaring that the surgeon general was falsely making any possessor of the MD degree “the sine qua non of therapeutic efficiency for war service.”80(p1) Gorgas' actions and Congress' refusal to overrule him likely served to encourage more DOs into enrolling in unaccredited medical schools in their desire to serve the troops. 
Yet despite their exclusion from the military medical corps, the osteopathic profession made some remarkable gains as a result of their wartime efforts. Numerous newspapers across the country covered the DOs lobbying campaign, and many editorially supported their cause. In addition, with so many MDs now abroad, the DOs found themselves taking care of the general health needs of more Americans at home. When in 1918-1919 millions of Americans contracted influenza and its common sequela pneumonia, DOs soon found that their manipulative medical approach to managing patients seemed to yield much better results than those achieved by MDs. The AOA began an effort to systematically gather statistics—not only to prove the success of osteopathic practitioners but also to support their lobbying efforts to secure Army and Navy medical commissions.1 
Hundreds of DOs submitted their case summaries, which were then compared with government-collected data. The AOA reported that only 1% of all DO-treated influenza patients died, compared with 12% to 15% of all treated patients. For patients with pneumonia, 8% of those treated osteopathically died compared with 25% under standard medical care. Although the publication of these favorable osteopathic treatment statistics did not get DOs military medical commissions, many osteopathic practitioners concluded that this published data demonstrated that the DO degree—and not the MD degree—was “the sine qua non of therapeutic efficiency,” at least with respect to going to war against these 2 lethal scourges.1,78 
Physician and Surgeon—DO
After the First World War, many local medical societies forced osteopathic physicians who had secured legitimate medical degrees to make a choice as to which profession they wished to belong. This was codified nationally when in 1923, the AMA Judicial Council ruled that osteopathy was a “medical cult” and all DOs were unscientific practitioners. No “ethical” member of the AMA or its divisional societies could henceforth advocate osteopathy or consult with osteopathic physicians. Where dual-degreed DOs long believed that they were serving to foster greater understanding between the osteopathic and allopathic worlds, they now saw that their dual identity had placed their continued livelihood in jeopardy.81,82 
Often the choice of dual-degreed practitioners as to which profession they should follow came down to the nature of their practice. Those dual-degreed physicians who were members of MD hospital staffs or who were dependent on MD referrals—such as Peck—generally chose to identify themselves as MDs. And in order for them to be in good standing, these practitioners were required to studiously avoid further public and even private contact with their osteopathic brethren. 
Unlike the AMA, the AOA did not institute any prohibitions on its members consulting or interacting with MDs. Nor did the AOA prevent or discourage those DOs who had secured legitimate MD degrees from employing them on their stationery or in public advertisements. Nevertheless, leaders of the AOA always had and continued to look with disfavor upon those osteopathic practitioners who claimed to be MDs on the basis of diploma-mill degrees or through short courses offered by unaccredited medical schools. It appears, however, that many of these practitioners had not even bothered to join the AOA, or if they had, decided to let their membership lapse. 
Although the AMA stepped up its legislative campaign against osteopathy throughout the 1920s, the colleges' implementation of the mandatory 4-year curriculum helped the lobbying efforts of the growing number of DOs who favored a broad approach to therapeutics.83 By 1925, 16 states had passed laws giving DOs the opportunity to secure the same legal scope of practice once reserved only for the possessors of the MD degree.84 
The broad osteopaths were encouraged, but they were also frustrated. They believed that far greater legislative progress would have been made if the AOA Board of Trustees had dropped its long-standing opposition to colleges teaching a full course in materia medica. In the JAOA and other journals, the broad osteopaths argued that there was now indisputable evidence to support the value of particular drugs, vaccines, and serums. They maintained that physicians—including osteopathic physicians—who did not incorporate these prophylactic and therapeutic means in a general practice were not affording their patients a recognized, scientific standard of care.1,85-89 
Under intense and continuing pressure from some of the colleges and the broad osteopaths, the AOA in 1927 permitted the schools to offer a course entitled “Supplementary Therapeutics.” However, osteopathic lobbyists soon learned that legislators with whom they spoke were unmoved. The lawmakers argued that if, as DOs maintained, the teaching in osteopathic colleges was now as broad and deep as that encompassed by medical schools, then osteopathic colleges should be honest and incorporate a course specifically titled “Pharmacology” and declare in their college catalogs that this subject covered the full range of generally accepted chemical and biological preventatives and therapies.1 
In 1929, the AOA finally allowed the colleges to add pharmacology to their curriculum if they so wished.90 This new policy meant that from a purely educational standpoint, future osteopathic graduates would need no other professional degree to complete the range of studies necessary in their training to become fully-rounded general practitioners. Now possessing a broad therapeutic armamentarium—indeed arguably more than graduates of MD schools—osteopathic practitioners would strive to be recognized by legislatures, by the public, and by telephone companies as “Physicians and Surgeons—DO.” Yet even as this transformation was occurring nationally, a committed group of practitioners in California envisioned a far different strategy and degree pathway to the legitimation of themselves as fully recognized physicians and surgeons.1 
   Financial Disclosures: None reported
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