The DOs: Osteopathic Medicine in America, 2nd Ed.

4. Structure & Function

With the movement rapidly growing, many DOs thought it desirable to coordinate their efforts and activities. In February of 1897, a small group of American School of Osteopathy alumni met in Kirksville and decided to establish a national organization for this purpose. Graduates of other schools were then invited to take part in the planning, and by April they had collectively launched the American Association for the Advancement of Osteopathy, which was renamed and restructured as the American Osteopathic Association (AOA) four years later.1 The officers of the AOA under its 1901 constitution included a president, two vice-presidents, a secretary, and a treasurer, all chosen for a twelve-month period of service, and a board of trustees whose members were appointed for staggered three-year terms. Members of the board were charged with responsibility for the day-to-day affairs of the association, while the general membership—in reality only those opting to attend the annual convention—elected all officers, including the board, and decided questions of policy.2 As the number of AOA members rose, this last feature of the system proved unwieldy, prompting those participating in the 1909 convention to enlarge the board from eleven to seventeen members and invest it with virtually complete control over policy issues.3 In 1919 a dual form of central government was restored when the House of Delegates was created based on the proportional number of members within each state. These representatives, who were chosen by their respective divisional societies, thereafter selected all other national office holders and acted as the business body of the association during its annual week-long meetings.4

From its inception, the AOA actively worked to secure the conditions necessary for the movement to obtain professional recognition. To protect autonomy, it fought for independent boards of registration and examination. Academically, it both significantly lengthened the standard course of undergraduate training and supported ongoing research projects. To improve members’ socioeconomic status, the association championed a code of ethics while combating the proliferation of impostors and imitators.

The Independent Board

At the turn of the century a majority of states were without a specific law governing osteopathy, and in several of the states with such an act, the legal position of the DO was hardly improved as a consequence. Early lobbying campaigns had usually been conducted by individuals speaking for only one segment of the emerging movement, leading to situations such as that in Vermont, which had extended practice rights only to graduates of the American School.5 In other states diverse osteopathic factions had appeared be fore the legislatures with varying recommendations. This lack of unanimity often resulted in a poorly constructed compromise or no law at all.

Several of the early practice acts placed the regulation of osteopathy under the jurisdiction of existing state medical boards. In some states a DO was added to these agencies; in others no representation was granted. Although osteopaths would be examined alongside MDs, taking the same written tests in such subjects as anatomy, physiology, and chemistry, they were exempted from answering questions concerning materia medica or therapeutics. In a few states this arrangement seemed to work out satisfactorily for the DOs, as they found they could do nearly as well as the allopaths in passing examinations and becoming licensed. However, before other similarly constituted boards DOs did not have comparable success, and in certain instances MD officials prevented any comparison between the two groups whatsoever. In Iowa, for example, the legislature granted the medical board the power of accrediting osteopathic schools, with only graduates from approved institutions becoming eligible for licensure. After a cursory look at their catalogs, the board rejected all osteopathic colleges, thereby preventing any DO from legitimately practicing in the state and thus circumventing the intent of the lawmakers.6

In 1901 the AOA created a permanent committee to insure the passage of favorable laws. Toward this end, the Committee on Legislation devised a standard model bill for every state, whose chief feature was the estab lishment of independent boards of osteopathic examination and registration. In this plan each divisional association would nominate a long list of candidates from which the governor of the state would choose five to seven as members. These individuals, once they had been appointed, would be responsible for testing DO candidates, negotiating reciprocity agreements with other boards, and disciplining errant practitioners.7 With the AOA trustees giving their strong backing to the idea, the committee began overseeing the lobbying efforts of the divisional societies. Frequently the societies faced a hard struggle. During the 1870s and 1880s, when medical practice acts were being reintroduced, several states granted the allopaths, homeopaths, and eclectics separate boards. This arrangement was sometimes difficult to administer and was often plagued with difficulties. Some states addressed these problems by abolishing this system and placing representatives of each sect upon a single, allencompassing board, where they all kept a watchful eye on one another.8 In appealing to those who either were undecided about or saw no need for independent osteopathic boards, Arthur Hildreth, DO (1863–1941), the first chairman of the Committee on Legislation, hastened to argue:

There has never been one single voice raised against osteopathy except by men of other medical schools. Every inch of progress made by our profession since its discovery has been contested by them. We have been looked down upon, criticized, ridiculed, called “faddists, masseurs” and everything but gentlemen. And now when securing recognition by law, should we secure representation from existing Boards of Examination and Registration, we should have to do so against their protest and through the influence of our many, many, good friends. And after securing representation upon their boards, what is our position? Are we loved any more by them? No, we are still at a disadvantage because they overwhelm us in numbers and ours being unwelcome company, we need not expect many favors. Certainly we shall receive no help to reach out and grasp greater and better things such as must and will come to us with the right kind of encouragement and conditions.9

This line of reasoning became increasingly influential over the years, particularly where elected officials became convinced that discrimination by MD boards did in fact take place. In 1913, ofthe thirty-nine states that had passed osteopathic practice laws, seventeen provided for independent boards. Ten years later, these figures had risen to forty-six and twentyseven respectively.10 Furthermore, even in many of those states whose legislatures refused to accede to all DO demands, bills were enacted recognizing the AOA as the sole accrediting agency of osteopathic colleges, thereby preventing prejudicial actions by MD-dominated boards. Accordingly, the profession won for itself a considerable degree of autonomy and legal security.

Lengthening the Course

The first group within the movement which attempted to set common educational requirements for DOs was the Associated Colleges of Osteopathy (ACO), founded in 1898 and composed of most of the legitimate schools. In fact, from the time of the ACO’s formation, eligibility for membership in the AOA was predicated on being a graduate of an ACO affiliated institution.11 The Associated Colleges was created in part to remove the ill feelings the schools bore towards each other because of their aggressive competition for matriculants. Certain competitive activities such as cutting tuition, stealing students, and shortening the time necessary to earn a diploma—were working to their mutual detriment. To stop these practices, each member of the ACO pledged to adhere to clear guidelines covering admissions, attendance, tuition, transfers, and advertising methods and to offer a mandatory two-year course.12 Despite their promises, some of the colleges continued to engage in these prohibited practices, which only engendered further suspicion and distrust. As it became obvious that the schools could not effectively regulate themselves, the American Osteopathic Association in 1901 ruled that henceforth it would designate which colleges’ alumni it would accept as members, in effect making the AOA the primary authority for establishing and maintaining academic standards.13

Looking at the state of osteopathic education at this juncture, leaders of the profession were convinced that major improvements were required. One of the critical areas of concern was the length of time needed to train and graduate DOs. Certainly the two-year curriculum of twenty months looked meager beside the four-year, thirty-six month program offered by almost all allopathic institutions. Wilfred Harris, DO, head of the Massachusetts school, argued, “The twenty month course is too brief. However clever the student, he cannot by any process of mental gymnastics, transplant himself with such suddenness from one field of thought and activity to another.”14 In 1902 the newly organized AOA Committee on Education issued a report urging the rapid establishment of a three-year course and the introduction of a four-year curriculum as soon as practicable.15 According to the committee chairman, Dr. C. M. T. Hulett, this “would give time for more exhaustive work in many subjects now too much abridged; would make possible a substitution of the laboratory for the lecture, in many cases, and permit good laboratory work being made better.”16

Not all DOs, however, saw matters in this light. Some believed that laboratory instruction was relatively unimportant. Others took the selfserving position that in adding one year and eventually another to the course, the profession would be declaring all previous graduates inferior or unqualified. This argument was skillfully answered by Dr. J. Martin Littlejohn, who, along with his brothers, had left Kirksville in 1900 to establish a school in Chicago. “The question is often asked did not our earlier graduates get along on much less time? Yes; but none have felt more than they the handicap that meant,” he declared. “We do not mean they have not succeeded. They did succeed, but theirs was a struggle to evolve their knowledge as they advanced. To the busy practitioner, this is no easy matter.”17

In 1903 the AOA and ACO jointly sponsored the first on-site survey of the schools. Chosen as inspector was Eamons Booth (1851–1934), who before becoming a DO, had earned a PhD from Wooster College and had taught at Washington University in St. Louis. In his report to the profession, Booth confirmed what others had already claimed in regard to the depth of preparation possible under the existing curriculum. His findings and recommendations helped to sway the undecided, and the AOA voted to require that all colleges inaugurate a compulsory three-year, twentyseven month course by September 1904.18

A number of schools harbored great reservations concerning this policy, fearing a sudden drop in matriculants. Three early members of the ACO had recently folded—the Milwaukee College (1898–1901), the Northern Institute of Minneapolis (1896–1902), and the Northwestern College at Fargo (1898–1903)—primarily because of insufficient enrollment. There was concern that the new requirement might accelerate this trend. Curiously, the greatest objections were raised by the most solvent of the colleges. Charles Still claimed that all of his father’s assets were tied up in the American School of Osteopathy and that in the event of its closure as a result of the proposed change, the “old doctor” would be ruined. The younger Still pleaded for an optional rather than mandatory three-year course, but the AOA rejected the request. However, they did by a narrow margin decide to give Kirksville an additional twelve-month grace period.19

While the total number of osteopathic matriculants markedly declined in the following decade, some schools were more dramatically affected than others. Closing their doors were the Colorado College of Denver (1897–1904); the Atlantic School, first of Wilkes-Barre, Pennsylvania, later of Buffalo, New York (1898–1905); the Southern School of Franklin, Kentucky (1898–1907); and the California College of San Francisco (1898–1910). In 1914 two other schools, the Los Angeles and the Pacific colleges, agreed to merge. By 1915 there were only seven recognized DO granting schools in operation, located in Boston, Chicago, Des Moines, Kansas City, Kirksville, Los Angeles, and Philadelphia.

For most of the surviving institutions the addition of the third year had unexpectedly worked to improve their financial situation, as the decrease in new matriculants was more than offset by the extra year of tuition each student paid. This emboldened all of them to initiate an optional fouryear course. In 191 l the Philadelphia school, spurred by recently enacted requirements for college registration in key states like New York, made the extra year compulsory for new matriculants.20 It was soon joined by the Chicago College.21 In 1914 the AOA Board of Trustees passed a resolution stipulating that the remainder of the colleges do the same no later than 1916.22 Although some of the schools once again feared dire consequences because of this move, they realized that they had no choice but to comply. By 1920 all graduates of approved osteopathic colleges had received instruction equivalent in length to that of their MD counterparts.

Scientific Publications and Research

In 1901 the AOA introduced the Journal of the American Osteopathic Association (JAOA), whose purpose was to inform members of organizational business and to advance scientific knowledge. Within two years the JAOA had become a monthly publication of approximately fifty pages. Its staff recognized that for the JAOA to become a truly professional publication, the quality of its articles on practice, particularly those based on actual case histories, would have to rise above the level then prevalent. As one prominent DO succinctly remarked:

It has long been appreciated by the public fully as well as ourselves, that osteopathic clinic reports in the true sense of the word DO NOT EXIST. What we call clinic reports and print in our magazines are a hodge podge of “hot air” and personal advertising in which we grant each other the right to advance rhetorically each his or her own personal reputation just as much as possible… When [in] issue after issue our papers print glowing reports of what we have all done, and at that over our own signatures, isn’t it just a little likely that the conscientious inquirer will say “Well do these people ever admit failures? Do they know what they fail to cure?”23

In order to improve the quality of osteopathic case reporting, the AOA Committee on Publication in 1902 appointed Edythe Ashmore, DO, of Detroit, to lead a campaign in which practitioners in the field would be encouraged to fill out and submit concise patient histories, the best of which would be published in sets of one hundred as a semiannual JAOA supplement. This effort, it was thought, not only would be good experience for the average DO, but would also help to support osteopathic claims. Ashmore mailed out forms specifying the type of information needed, including client’s age, sex, marital status, occupation, family history, prior treatment, symptoms, physical signs and diagnosis, what osteopathic lesions were present, the causes of disease other than lesions, and what urinalysis and other laboratory tests revealed. In terms of therapy, Ashmore requested descriptions of the specific manipulative technique employed, the length of the treatment, and changes in method as the case progressed.24

The first series was published in 1904, the last in 1909.25 In each installment, cases were divided into eight broad disease classifications. Representation of given disorders did not always reflect the frequency of their appearance in a typical osteopathic practice; rather, many patient histories seem to have been selected on the basis of their value in demonstrating the alleged breadth of Still’s approach. While most of these printed cases were described without the needless bluster, self-advertising, and harangues against the MDs, serious qualitative problems in the reports remained. Only a small number of examples where manipulation was found to be ineffective were included. Though these supplements were not meant for distribution to patients, most DOs had no desire to appear as anything less than successful before their peers either. Another difficulty was the lack of consistency in diagnostic findings. In a given condition, for example asthma, one DO would have found lesions along the cervical spine, another in the dorsal area, while a third would have located them in the lumbar region; and each would announce positive results by manipulating only where the lesions had been palpated.26 These seemingly conflicting reports did not help the DOs refute charges by their MD critics that such lesions were imaginary and that osteopaths wrought their cures simply through suggestion.

As this weakness became manifest, influential DOs sounded a call for original scientific studies to “prove the lesion.” In 1906 the AOA voted to establish and partially endow a separate institution to serve the dual function of conducting basic research and teaching advanced courses to DOs already in practice. Opposition to this plan was soon voiced by the colleges, several of which were already offering their own graduate-level classes and felt that the creation of a national center for this purpose would only lure away their students and fees. After three years of wrangling with the schools, the AOA agreed to drop the idea of a teaching role from their proposal, at which point financial contributions began to be solicited in earnest. By 1913 sufficient funds had been raised to purchase and equip a small building in Chicago which became known as the A. T. Still Research Institute.27

The first director of the institute was John Deason, DO (1874–1946), an American School of Osteopathy alumnus with an MS degree from Valparaiso University. He had also taken a postgraduate course at the University of Chicago, where he published a paper entitled “On the Pathways of the Bulbar Respiratory Impulses in the Spinal Cord” in the American Journal of Physiology.28 Several of Deason’s experiments and those of his associates centered on producing artificial “bony lesions” upon animal subjects and determining what effect, if any, they had on certain physiological functions. For the purpose of their research a bony lesion was defined as a slight dislocation or subluxation of a vertebra in relation to its adjoining segments. This was induced by manual adjustment of the sub ject under anesthesia and was verified immediately following and on regular intervals thereafter through digital palpation. In the first published compilation of their work, Deason and his colleagues recorded significant changes in carbohydrate metabolism, peristalsis, blood pressure, bile flow, and renal output following the artificial production of these lesions. However, their evidence supporting causal relationships was less than compelling.29

In 1917 a West Coast branch of the institute was established outside of Los Angeles and headed by Louisa Burns, DO (1868–1958), a 1903 graduate of the Pacific College who had later obtained an MS degree from the Borden Institute of Indiana.30 When Deason left basic research for private practice during the First World War, Burns emerged as the profession’s only full-time investigator. Her experiments were similar to those that had been carried out by the Chicago group, with some modifications. In her long career, Burns wrote several books and monographs in which she claimed that a variety of functional and organic disturbances of the eyes, heart, lungs, kidneys, stomach, and other viscera in laboratory animals were directly attributable to artificially produced lesions.31 Although she never published in outside science journals, many of her DO contemporaries were convinced that her internally financed studies demonstrated the soundness of their system. However, Burns failed to provide adequate controls, and her conclusions were not consistently derived from the data she presented.32 As a consequence of these inadequacies in her accounts, and because little other research into the basic science of osteopathy was being carried out at the colleges prior to the Second World War, fundamental questions concerning the etiology and role of the lesion in disease remained unsatisfactorily answered.

The Code of Ethics

In the early days of the movement, rarely did one osteopath locate his practice near that of another, except in major cities. However, as the number of new DOs increased, it became common for two or more to serve a relatively small town. In such communities, particularly where osteopaths and allopaths competed for limited health dollars, price wars and instances of character assassination took place. These occurrences made osteopathy appear as something other than a lofty calling—an impression furthered by those DOs who engaged in indiscriminate advertising.33

In 1904 the AOA adopted a formal code of ethics establishing guidelines for proper professional conduct. This document, based in part upon the code of the American Medical Association, emphasized cooperation rather than competition. To eliminate price wars, all DOs in a given geographical area were encouraged to formulate definite rules governing “the minimum pecuniary acknowledgment from their patients.”34 This concept was not unheard of within the ranks prior to establishment of the code. Members of the Washington State Osteopathic Association had agreed two years earlier to abide by a uniform fee schedule, charging no less than $2.00 for single office visits, $2.50 for single house calls, and $3.00 for single night visits. Chronic cases were billed at $25.00 for the first month, $20.00 for the second, and $15.00 for each subsequent one. Ministers and schoolteachers received special reduced rates, while the poor were to be treated for free.35 With the AOA now behind this type of arrangement and the Washington plan working to the participants’ satisfaction, several other divisional and local societies devised their own schedules.

The code of ethics also prohibited DOs from pirating one another’s clients, declaring:

The physician, in his intercourse with a patient under the care of another physician, should observe the strictest caution and reserve, should give no disingenuous hints relative to the nature and treatment of the patient’s disorder, nor should his conduct directly or indirectly tend to diminish the trust reposed in the attending physician… A physician ought not to take care of or treat a patient who has recently been under the care of another osteopathic physician, in the same illness, except in the case of a sudden emergency, or in consultation with the physician previously in attendance or when that physi cian has relinquished the case or has been dismissed in due form.36

Significantly, the code was ambiguous on whether this last courtesy was to be extended to MDs.

Unethical advertising was also denounced in this document, and later the AOA published a list of what it found to be the most offensive practices. These included buying newspaper space, publishing field literature that contained a “percentage of cures,” and issuing statements the truth of which was open to legal question.37 The association did not frown on all advertising, however. One type of promotion which was looked upon with great favor was the lay-oriented osteopathic health journal, such as the one established by Dr. Henry Stanhope Bunting (1869–1948). Working as a reporter for a Chicago newspaper, Bunting was sent off to Kirksville in the mid-1890s to write a story on Still and his movement. Impressed with what he found, he soon returned to enroll. After graduating with his DO degree in 1900, he settled again in Chicago, where he started a practice and took night classes at a medical college to further his education. In 1901 the busy Dr. Bunting introduced two continuing monthly publications; the Osteopathic Physician, for the practitioner only, dedicated to voicing all sides of every professional controversy; and Osteopathic Health, which was aimed exclusively at the general public. Compared to previous lay literature, OH, as it was commonly called, contained little in the hard-sell vein. Instead, there were broad discussions of the philosophy, principles, and practice of osteopathy. Bunting, who maintained an avid interest in advertising theory and wrote a textbook on the subject, believed that the most effective means of getting the attention of people was via the underplayed message.38 Needless to say, this meant a more dignified approach. A D0 in the field could send Bunting a list of names and addresses of actual or potential patients, and for a standard fee Bunting would notify those so-designated that they would receive a oneyear subscription to OH, into each issue of which he would insert a professional card of the practitioner paying for the service. As this system became popular, the AOA in 1914 decided to publish its own lay vehicle, the

Osteopathic Magazine, which also included general articles that were not health-related. As each of these and other new advertising ventures demonstrated their value in generating new business, the desire for and use of more questionable methods greatly diminished.

For those members of the AOA who were unwilling to abide voluntarily by the provisions of the code of ethics, disciplinary action became necessary. Every year the Board of Trustees investigated alleged misconduct, suspending or expelling those found guilty of serious violations from the ranks of the association. However, not all osteopaths sought membership in the AOA. In 1918 only 51 percent of the approximately 6,000 DOs belonged. In 1930, 57 percent of roughly 7,600 practitioners were in the fold.39 Thus, for several decades almost one-half the total number of DOs were outside the influence or control of the AOA. This jurisdictional gap was filled to some extent by the state osteopathic or medical boards of registration and examination, which had the power to revoke licenses for a variety of reasons coming under the heading of unprofessional conduct. Therefore, although instances of disreputable behavior would continue to be a problem for the movement, organized osteopathy had established the basic institutional mechanisms for dealing with unethical practitioners.

Impostors and Imitators

By the turn of the century, correspondence schools teaching osteopathy were springing up around the country, particularly where there were no osteopathic practice laws yet in force. In Ohio, for example, a man claiming to be an MD as well as a DO offered a teach-yourself-at-home textbook and a handsome diploma, both of which could be purchased for only $25. In New York, where the cost of living was considerably higher, a Norwegian ex-sailor announced a similar service for $100.40 The number of bogus osteopaths thereby produced can only be guessed at; nevertheless, their impact was undeniable. S. C. Matthews, a D0 in Wilkes-Barre, Pennsylvania, complained, “There are towns within my knowledge where disreputable and bungling methods of the unauthorized and uneducated practitioner have so injured the name of our science, that a legitimate osteopath would have the utmost difficulty in establishing himself. At best, it would be a struggle of many weary months.”41

Since the correspondence schools depended upon newspapers and magazines to attract their “students,” the Committee on Education, to whom the AOA Board of Trustees assigned the task of closing them down, decided they would first focus their efforts on the periodicals themselves. The committee reasoned that if publishers were made aware of the absurdity of these charlatans’ claims, they would refuse to carry their messages. It sent a standard letter that read in part: “Would you accept the advertisement of an institution which offered to fit persons for the practice of medicine by a correspondence course of study? Yet it is just as impossible to fit a person by mail for the practice of osteopathy.”42 So that publishers could better appreciate the situation, the committee attached to their plea a description of the minimum requirements a college needed to obtain AOA approval, plus an abstract of existing state statutes. Most of those so contacted wrote back that they would henceforth reject such ads, and in 1907 the committee reported to the AOA Board of Trustees that there remained only one magazine of any sizable circulation that refused to honor their request.43 Though the selling of mail-order diplomas did not end as a result of the committee’s actions, it ceased to be a critical issue for the profession, especially as osteopathic legislation grew more widespread and those practitioners with unearned degrees became subject to prosecution under the law.

Quite a different problem, however, was presented by those individuals practicing what appeared to many to be osteopathy under a different name. The most numerous of these were the exponents of chiropractic, founded by Daniel David Palmer (1845–1913). According to Palmer the principles of this system were fashioned by him in 1895 , while he was making a living as a magnetic healer in Davenport, Iowa. A janitor who worked in the building where Palmer kept an office told the practitioner that he had gone deaf seventeen years earlier after something “gave way” in his back. Reasoning that a displaced vertebra was responsible, Palmer manipulated the spinal segment into its proper position, and the janitor announced that his hearing had returned. Based on this and subsequent cases so treated, Palmer declared that 95 percent of all disease was due to “subluxated” vertebrae.44

In 1898 Palmer began to teach his methods. Initially he found few followers, training only 15 students through 1902. Business picked up for a while, but then Palmer’s personal good fortune declined. In 1906 he was convicted of practicing medicine without a license and was sentenced to spend six months in jail. During his incarceration, his school was taken over by his son, Bartlett Joshua Palmer (1881–1961). The two were better known as BJ and DD. When DD was released, BJ squeezed him out of the college, whereupon DD tried without success to operate schools elsewhere. Returning to private practice, the elder Palmer wrote a massive textbook, a significant portion of which was devoted to a diatribe against his son. Bitter feelings between the two remained strong. At a founder’s day parade held in Davenport in August of 1913, the uninvited DD, marching on foot, was struck from behind by an auto driven by BJ. DD died a few months later, with some of his followers convinced that his death was a consequence of his injuries.45

Under the younger Palmer the school continued to grow, securing many matriculants by sensational advertising—a practice BJ encouraged his followers to emulate. By 1916 there reportedly were some fourteen hundred students in attendance, taking one year’s training leading to a doctorate in chiropractic, or DC, degree. For those who could not appear in person, a correspondence course was instituted. As the Davenport college flourished, dozens of other chiropractic schools, the great majority of them engaged in the selling of diplomas, were established across the country.46

Many early chiropractors were arrested on the charge of practicing osteopathy without a license. Unlike those with fake DO diplomas, however, chiropractors claimed that they were not pretending to be osteopaths and were therefore innocent of any offense. In court they cited a number of differences between the two systems. The DOs, they pointed out, commonly adjusted several vertebrae to treat a given disorder; they invariably adjusted but one. The technique also varied. Osteopathic manipulations were based on the lever principle, namely, the application of pressure on one part of the body to overcome resistance in motion elsewhere. This meant twisting the patient’s torso in certain directions while maintaining a steady hold upon the point to be influenced.

The most common chiropractic procedure of the era had the client lying prone with little, if any support below the spine. The operator would then place both hands directly over a vertebral segment that was believed to be “subluxated” and administered a quick thrust downward with all possible force. In court, when DO witnesses were called to the stand, they would often testify that this method was crude and dangerous and would not be employed in osteopathic practice. Such statements, however, unintentionally worked to the chiropractors’ advantage, since they indicated to juries that there were indeed divergences in approach. With respect to the element of danger, the defendants were only too glad to present patients who had been so treated, attesting to the safety of such maneuvers.

To further cement their position, some chiropractors cleverly managed to obtain and circulate signed letters by officials of recognized DO-granting schools stating that a course of chiropractic was not the same as one in osteopathy. As a result of these tactics, they generally won acquittal.47 Since the courts were beginning to establish the chiropractors’ right to engage in their livelihood outside the jurisdiction of either the medical or osteopathic licensure acts, several legislatures realized that unless they passed laws recognizing the group, their states would be inundated with diploma mill graduates. In 1913, despite vigorous lobbying of MDs and DOs alike, Kansas and Arkansas became the first to enact chiropractic bills. Each required for licensure an eighteen-month course of personal instruction at a duly chartered college. By 1922 twenty other states had similar statutes.48 At this time the number of DCs legally and illegally in practice probably exceeded the number of osteopaths in the country. Thus, while the DOs, through the AOA, had made considerable progress in obtaining some professional recognition insofar as certain measures of organization, autonomy, socioeconomic status, and education were concerned, they nevertheless could not prevent the rise of others who could more inexpensively and quickly produce practitioners capitalizing upon the therapeutic modality that was the central feature of the osteopathic system.49

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