CHAPTER 17 OSTEOPATHIC MEDICINE

To find health should be the object of the doctor. Anyone can find disease.

—ANDREW TAYLOR STILL, MD, DO, FOUNDER OF OSTEOPATHY

HISTORY

Osteopathic medicine began as an offshoot of the standard, “regular” medical practices of the 1800s when one innovative physician became disenchanted with the inadequate and harmful effects of the medicines being used by the doctors of that era.

Andrew Taylor Still, MD, DO, was born in 1828 in Jonesboro, Virginia, when this part of the country was still on the American frontier. His life experiences and observation led him to question the entire system of medicine that existed in nineteenth-century America.

Most medications used in that era were unresearched remedies passed on through tradition from the Middle Ages of Europe. Bleeding and leeching were major components of treatment when Still was trained, as were “purging and puking.” One of the most common medications was calomel, a mercuric compound used as a purgative. It was extremely toxic, often causing patients’ gums to be resorbed, teeth to fall out, and sores to break out in the mouth. Calomel undoubtedly contributed to many deaths and disfigured many more. Surgery was primitive and performed without antisepsis; anesthetics were just beginning to be used in the mid-1800s. No antibiotics had been identified, and no microbial cause of infectious illness was proven until 1872. There was no knowledge of the immune system, and heart disease and cancer were not understood. Physicians were capable of diagnosing empirically recognized patterns of illness and, in many cases, predicting outcomes. Medical treatment was often more dangerous than doing nothing. In fact, the famous French mathematician and philosopher Descartes (see Chapter 6) was reputed to have said, “Before, when I knew I was sick, I thought I might die; now that they are taking me to the chirurgeon, I know I shall” (Schiowitz, 1997).

Still was seeking a philosophy of medicine and system of treatment based on scientific principles as they could be observed in nature. In one of his books, he stated that in April 1855, he began to discuss reasons “for my faith in the laws of life as given to men, worlds, and beings by the God of Nature” (Still, 1902). He was not alone in his disillusionment with the contemporary state of affairs and quest for a scientifically based philosophy of medicine. The great physician and author Oliver Wendell Holmes, for example, was often quoted from his presentation to the Massachusetts Medical Society (publisher of today’s New England Journal of Medicine) that “if the whole of materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes” (Holmes, 1892). (The jurist Oliver Wendell Holmes, Jr., Supreme Court chief justice, was his son.)

By the time of the Civil War, a large number of American physicians were homeopathic or eclectic (nonstandard) practitioners. In addition, many people on the frontier took care of their own medical needs (see Chapter 1). Medical education was offered in two ways, one by university degree and one by “reading medicine.” At university-affiliated medical schools during the early and mid nineteenth century, students attended a course of 4 months of morning lectures to obtain their degrees. If students voluntarily attended a second year, it was for a repeat of the same lectures. The alternate pathway was used by many American physicians on the frontier, who learned by becoming an apprentice to an established physician. Under the physician’s supervision, they read medical and scientific textbooks and accompanied him and possibly other of his colleagues on home and office visits. More specialized studies could be undertaken by arranging to work with an established expert, but most doctors did not pursue such studies. These two systems were later combined and evolved into the current system of medical education (2 years of basic science and medical didactics, followed by 2 years during which students continue to read medical books and journals while shadowing and assisting physicians in hospital and ambulatory care settings, after which the graduate physicians do an additional 3 to 7 years of supervised postgraduate hospital residencies).

Andrew Taylor Still (Figure 17-1) was the son of Abram Still, a circuit-riding Methodist minister who was also a physician, tending to his flock both spiritually and medically. Shortly after Andrew Taylor was born, the family moved from Virginia to Missouri, further out on the nineteenth-century frontier, so that his father could serve the needs of the church in the west. Abram Still was an ardent abolitionist who sided with the small minority of Methodist ministers in Missouri who were opposed to slavery. There were terrible insurrections in the Kansas and Missouri territories over whether they would be admitted to the Union as slave or free states. When the church split over the issue, the elder Still moved the family to Kansas, where they supported the cause of freedom.

Figure 17-1 Portrait of Andrew Taylor Still, the founder of osteopathy, ca. 1900.

(Courtesy Kirksville College of Osteopathy, A.T. Still Memorial Library, Archives Department, Kirksville, Mo.)

Like many pioneer boys, the younger Still grew up contributing to the family food supply by hunting and did much of the butchering of the animals himself. He later stated that his studies of anatomy began this way. In his autobiography, he described an intense headache that occurred when he was 10 years old. To alleviate his discomfort by taking a nap, he placed his jacket over a rope swing to construct a pillow and then lay down with the base of his skull over the other side of the rope. He fell asleep and a short time later awoke to find his headache gone. This phenomenon impressed him, and when he became a physician, the memory of it led him to think about the relationship between the body’s anatomy and the disease process. He was perhaps engaging in an early form of craniosacral therapy or myofascial release.

Still obtained his medical education through the process of apprenticeship under an established physician (in Still’s case, assisting his father), combined with reading the medical texts of that time. He later attended a medical school in Kansas City, but he did not complete a degree, stating that the school had little to teach him that he did not already know.

The younger Still began his medical career by serving the local community and working with his father with the Shawnee Indian tribe. Ironically, many years earlier his maternal grandmother had been kidnapped by the Shawnee, who had also killed numerous members of that generation of her family. Still had a standard general medical practice, employing the usual medications and involving the full range of available treatment, including obstetrics and minor surgery.

Dr. Still became a battalion surgeon in the Kansas militia during the Civil War; he also served as an officer and led men into battle. He returned to his family in 1864 at the end of the western campaigns, when the Kansas militia was disbanded after the Union victory.

Believing that his family was safe now that the war was over in that part of the country, he was stunned when three of his children died in an epidemic of spinal meningitis. There were no effective medications to treat such an illness. He called other physicians to attend to his family, rather than manage their cases himself, and called ministers to pray for the children as well. Nothing availed, and the children died. This event caused him to question the entire foundation of medical care in his era. He wrote, “It was when I gazed at three members of my own family—two of my own children and one adopted child—all dead from the disease, spinal meningitis, that I propounded to myself the serious questions ‘In sickness has God left man in a world of guessing? Guess what is the matter? What to give, and guess the result? And when dead, guess where he goes?’” (Singer et al, 1962).

Seeking a more enlightened practice of medicine, Still based his reasoning on the Methodist philosophy of working to attain perfection, which seemed to have something in common with the new idea of natural evolution. The early evolutionists suggested that there existed a natural process of working toward perfection of the organism and that the human being was the highest naturally evolved life form. Still felt that the human being was perfectly constructed by the one he later referred to in his writings as the God of Nature, the Great Architect, the Great Engineer, and the Great Mechanic. If the human body was perfectly constructed as the highest form of machine, he felt it should simply need fuel and, if something went wrong, adjustment.

Like the general population of the nineteenth century, he had a tremendous admiration for engineering and all things mechanical. Still was also an inventor; during his life he invented a thresher and obtained patents for a new type of churn and stove. He would eventually tell the students at the American School of Osteopathy that they were to become human engineers who knew every part and function of the body. They were to find engineering solutions to human illness and dysfunction.

Even before the Civil War, in the 1850s, Still experimented with manual treatment of patients. But this was in addition to the use of standard medical practices. It was after the war, and the death of his children, that his ideas came together into a complete philosophy regarding the etiology of illness and how to treat it. By 1897, Still wrote in his autobiography that it was on June 22, 1874, that he “flung to the breeze the banner of osteopathy” (Singer et al, 1962). Apparently it was by that date that he was able to define the principles on which his philosophy and practice of medical care would be based. His new methods involved hands-on treatment adjusting the positions of joints and levels of muscle tone; enhancing the circulation of blood, lymphatic, and cerebrospinal fluids; improving the efficiency of respiration; and therefore improving host response to disease.

Still was ostracized in Kansas for leaving the medical fold and denied the opportunity to teach his new ideas at Baker University in Baldwin, Kansas, a Methodist university where he had hoped at least to be able to discuss his ideas. He and his family had donated land to start the university, and he and his brothers had built a mill and sawed timbers for the original building. The local minister, however, indicated to the congregation that his practice was of the devil, because only Jesus was supposed to be able to lay hands on the sick and heal them.

After a period of time and a severe illness, he moved to back to Missouri, finally settling in Kirksville, where he said he found a few people who were willing to listen to reason. He set up a circuit practice of medicine in outlying communities. After Still had been in practice for a while so many people began coming to Kirksville looking for him that he was able to stay in one place. He was not sure what to call his clinical practice. At first he thought his new methods, being hands on, might have something in common with magnetic healing, which was a popular nineteenth-century practice following on Mesmer’s concepts of “animal magnetism” and energetic healing (see Chapter 6). Thus for a short time Still called himself a “magnetic healer.” Later, he used a business card on which he called himself a “lightning bonesetter.” The use of this term implies that he had heard of the folk healers who called themselves by that name. There is no evidence, however, that he ever studied with anyone who had learned this art in the usual way (i.e., it was passed from one person to the next, such as from father to son).

Still coined the term osteopathy (from the Greek roots osteon and pathos) sometime prior to founding the American School of Osteopathy (ASO) in 1892. This nomenclature followed the tradition of naming medical approaches after what was considered the central issue in pathology or cure (e.g., homeopathy, hydropathy, naturopathy). In the case of osteopathy, Still reasoned that malpositioning of bones and joints, especially in the spine, affected both circulation and nerve function, providing the opportunity for the development of disease in the tissues. William Smith, educated in Scotland, was another reform-minded MD who offered to teach anatomy in the new school if Still would teach him his methods. About 10 students began the first year. The school expanded rapidly, and it became impossible for Still to personally instruct all the students in his methods; thus over the next few years his first students became the new professors. Other physicians and college graduates joined the faculty as the curriculum and number of students expanded.

To further disseminate his ideas, Still wrote four books. The Autobiography of Andrew T. Still (1897) describes his life and how he developed osteopathy. The Philosophy of Osteopathy (1899) and The Philosophy and Mechanical Principles of Osteopathy (copyrighted in 1892 but published in 1902) describe his philosophical ideas and contain a great deal of then-current simple knowledge as well as speculation about physiology, a subject poorly understood at the time. In Osteopathy, Research and Practice (1910), Still continued to expand on his ideas and described some of his treatment techniques.

These books reveal that he still, on occasion, used some medications—although extremely rarely. He was opposed to the use of opiates and alcohol, having seen much abuse (especially in Civil War injured and disabled), and specifically stated that it was foolish for physicians to dissolve most medications in alcohol, because this practice could lead to dependency. Throughout his books he recommended the use of manipulation to relieve anatomical and therefore physiological stress on the system, and return the body to a state in which it could cure itself through normal physiological processes. Still’s original philosophical principles are summed up in “Our Platform,” which was published in Osteopathy, Research and Practice, and adopted by the ASO as the foundation of its educational program.

The allopathic profession, which was becoming successful in establishing a monopoly on medical training and licensure, vigorously fought the new osteopathic profession. Still’s followers, however, achieved great success in their treatment of illness in comparison with their MD counterparts, effecting cures in some “hopeless” cases and treating all types of illnesses. The new doctors also had special expertise in neuromusculoskeletal conditions at a time when no physical medicine, rehabilitation, or physical therapy was available to the public. The ASO rapidly expanded, and new schools founded by graduates helped build the osteopathic profession, which attracted supporters such as Teddy Roosevelt, President William Howard Taft, and Mark Twain (who testified to the New York State Assembly in favor of osteopathic licensure). Osteopaths graduated with the title Doctor of Osteopathy (DO), which was changed at the end of the twentieth century to Doctor of Osteopathic Medicine (DO).

The 1910 Flexner Report, sponsored by the Carnegie Foundation, compared all American medical schools against a standard represented by the new Johns Hopkins University School of Medicine. Criticism was so devastating that about three quarters of American medical schools closed, including many osteopathic medical schools. The surviving osteopathic medical colleges were located in Kirksville, Missouri; Kansas City, Missouri; Des Moines, Iowa; Philadelphia, Pennsylvania; Chicago, Illinois; and Los Angeles, California. None of these schools received public funding at the time. The osteopathic profession was on its own for further development.

Still’s central idea was that structural abnormality causes functional abnormality, leading to illness. To restore health, treatments were designed to use the body’s own resources. He theorized that manipulation would increase the body’s efficiency, promoting appropriate delivery of blood, return of blood and lymph, delivery of neurotrophic substances, and transmission of neural impulses. Physicians had relatively few medications of value for the patient in the preantibiotic era (during the early 1900s). Osteopathic manipulation, on the other hand, was a technique that a physician could use to effect physiological changes and help stimulate a host response against illness. In addition, osteopathy directly addressed a number of needs with which the medical profession had not successfully dealt: joint pain, physical rehabilitation, and soft tissue injuries.

Soon after Still’s death in 1917, his new osteopathic physicians were put to the test during the Spanish influenza pandemic of 1919. The results were excellent. The medical profession had little to offer patients other than antitussives, opiates, and strychnine to stimulate the heart. Osteopathic treatment targeted autonomic changes, blood delivery, lymphatic drainage, and biomechanical improvement in respiration. Osteopathic physicians reported dramatically lower morbidity and mortality rates among their influenza patients.

Between the death of Still in 1917 and World War II, osteopathic colleges, like allopathic colleges, gradually improved standards. In the early 1900s, increasing practice of antiseptic procedure helped improve the safety of surgery, as did the development and use of the sulfa antibiotics by the 1930s. Penicillin, although developed in 1927, was not available for practical use until it was mass produced by Florey and Chain for soldiers and sailors during World War II. Even after the problems of mass production were solved, it was not readily available for the American public until after the war.

Still’s students had included MDs who were less opposed to standard medications but integrated his ideas on enhancing the body’s own self-healing abilities by treating the structure (anatomy) to enhance the function (physiology) and restore health. By 1928, materia medica (the part of medicine concerned with formulation and use of remedies or natural pharmacological preparations, taught in allopathic medical schools before the development of modern medications) was taught at all of the osteopathic medical colleges. In addition, the newly researched and efficacious antibiotics were discussed as they were developed. Osteopathic physicians, along with their MD peers, increasingly had available medications that actually worked, which they used in their general practice of medicine. From Still on, early osteopathic physicians had included surgery in their complete practice of medicine (although, like their counterparts, not all personally performed the surgeries). DOs believed that osteopathic manipulation before and after surgery helped patients tolerate procedures better and reduced the incidence of complications, such as pneumonia, thereby resulting in a shorter recovery time.

As medical specialties and subspecialties were being developed, most osteopaths were general practitioners. American postgraduate training programs were not generally open to DOs. A number of osteopathic specialists obtained their training in Europe from physicians who did not concern themselves with distinctions between types of American physicians; some of these osteopathic physicians returned and set up specialty training programs in their own professions.

During World War II, osteopaths were not allowed to serve in the armed forces as physicians. Although some volunteered and served in other capacities, many stayed home and took care of patients whose MDs were overseas. Although DOs were not allowed to serve during World War II, a benefit was that, while MDs were overseas serving, many families in the United States began to receive treatment from DOs. Patients were unable to see their regular physicians, and this situation helped the growth of osteopathy.

In the postwar period, as returning soldiers attended universities in record numbers on the GI Bill, osteopathic colleges enrolled record numbers of students.

By 1953 the president of the American Medical Association (AMA) had called for and received a report on the status of osteopathic medicine, which indicated that DO training was equivalent to MD training. MDs in general became less concerned with whether their osteopathic colleagues used osteopathic manipulative treatment (OMT) in the care of back pain, in sports medicine, and in rehabilitation, as long as they also prescribed new medications that were proven to be effective.

Two other events in the middle to late twentieth century helped the osteopathic profession gain acceptance. One was the merger, by government regulation, of the osteopathic profession with the allopathic medical profession in California. A second was the establishment of 10 additional osteopathic medical colleges between 1969 and 1981, soon followed by others in the 1990s.

In 1961, California had more DOs than any other state. The state government, however, felt that the American Osteopathic Association (AOA) was unresponsive to its influence and decided to support a merger with the allopathic medical profession. The state osteopathic medical association worked with the California Medical Association to lobby with the public in support of this merger of professions. It was difficult at the time for DOs to obtain admission privileges in most allopathic hospitals, although osteopathic physicians had built their own hospitals. Voters were convinced to support a plan under which new osteopathic licenses would no longer be issued, with the provision that any DO who wished to do so could trade the DO degree and $65 for an MD degree and license. More than 2000 DOs accepted MD degrees and licenses. Benefits to the new MDs included new access to hospital privileges. The largest and arguably most modern osteopathic medical school, the College of Osteopathic Physicians and Surgeons at Los Angeles, was transformed into an MD-granting institution, which shortly thereafter affiliated with the University of California at Irvine.

The rest of the osteopathic profession was immediately concerned that the medical establishment, unable to eliminate the osteopathic profession, was attempting to absorb it. Although there was talk of offers similar to California’s in other states, there was no continuation of the process. Instead, the developments in California paved the way for further acceptance of the osteopathic medical profession. California MDs had seemingly indicated that the main differences between the two types of physicians were the letters of the degree and $65, and the osteopathic medical profession used this ammunition to approach state legislatures and other authorities in defense of osteopathic medical practice rights. Some state legislatures became convinced that it was in their interest to fund colleges of osteopathic medicine when statistics revealed that most DOs practiced general medicine and that a large proportion did so in underserved areas (small towns, rural areas, and inner cities).

The osteopathic medical profession rapidly approved the founding of numerous new osteopathic medical colleges, both public and private. Included among the state-funded colleges were schools in Michigan, Texas, Ohio, West Virginia, and Oklahoma. This rapid expansion continued the trend toward assimilation into the medical mainstream. In the latter part of the twentieth century there were insufficient numbers of osteopathic physicians to serve as role models, as well as a shortage of postgraduate training positions in osteopathic hospitals, and different interest levels in osteopathic student matriculants. The number of osteopathic graduates entering allopathic residencies increased, and young osteopathic physicians began dispersing throughout other hospitals rather than remaining concentrated in osteopathic hospitals.

In the meantime, the development of the osteopathic profession continued around the world and differed markedly from the American evolution of the profession.

OFFSHOOTS OF THE OSTEOPATHIC PROFESSION

As osteopathic techniques were adapted and used by others who had become convinced of their efficacy, offshoots of the osteopathic profession developed. The first person to investigate osteopathy and found another profession was D.D. Palmer, who originated chiropractic. Palmer also initially called himself a “magnetic healer” after Mesmer with his principles of animal magnetism. In his book The Lengthening Shadow of Dr. Andrew Taylor Still, Arthur Hildreth, one of the first students at the ASO, mentions that Palmer was a guest of Still’s, who often hosted students for dinner (Hildreth, 1942). According to Hildreth, Palmer accompanied a friend in the pioneer class who returned for his second year of instruction and appeared to be interested in becoming a student at the ASO. After learning some manipulation from Still’s students, he returned to Davenport, Iowa, and later “discovered” what he called chiropractic.

Stories passed down in families in the profession suggest that Palmer may even have registered as a student for a period of time, but written evidence of this has not been discovered. What is clear and indisputable is that Still, a physician, practiced in northern Missouri as a magnetic healer for almost 20 years before founding his school in 1892. Davenport, Iowa, is not far from Kirksville, Missouri, and Still’s reputation was attracting attention from near and far. Whether or not Palmer was a student of Still, it would not be surprising if his “serendipitous discovery” of manipulation in 1895 was based on what he had heard of Still’s methods. Palmer founded his own school in 1897.

Still’s original students attempted to practice as Still himself had practiced. However, he told his students that they did not have to do exactly as he did provided they could achieve the same results. Granted this freedom to explore, they quickly developed high-velocity manipulative techniques that were passed on at the school. The original chiropractic techniques resembled the high-velocity joint-resetting techniques used and described by some of Still’s original students more than the techniques Still himself used, which would support the notion that Palmer learned from the osteopathic students. By 1915, Edyth Ashmore, DO, who was in charge of teaching manipulative technique at the ASO, recommended in her published manual that the students not be taught the original methods of Still, because they were too hard for the students to learn.

Ida Rolf, the founder of rolfing (see Chapter 16), a method of bodywork, was clear in her writings that she learned techniques from a blind osteopath and combined them with a knowledge of yoga to create a systematic protocol for whole-body structural integration.

Other adapters of osteopathic technique (and partially of osteopathic philosophy) include John Barnes, a physical therapist who studied myofascial release offered in postgraduate programs at Michigan State University (MSU) and then taught it to physical therapists; and John Upledger, a DO who mixed cranial and other manipulative techniques taught by Still’s student William Garner Sutherland, DO, with light trance work and other techniques to develop what he called craniosacral therapy, which is generally practiced by nonphysicians.

In addition, because of the availability of postgraduate programs such as those offered by MSU and courses offered by other osteopathic physicians, physical therapists in the United States began using osteopathic techniques such as muscle energy, myofascial release, counterstrain, and even high-velocity low-amplitude thrust. The effect of osteopathic manipulation on physical medicine, rehabilitation, sports medicine, and family practice throughout the United States has been considerable, with many health care professionals and lay personnel learning osteopathic methods of alleviating pain and enhancing physical function.

OSTEOPATHIC PHILOSOPHY

Andrew Taylor Still developed a unified philosophy of medicine in the last half of the nineteenth century, which he called osteopathic philosophy. The word philosophy often engenders an immediate visceral response in the scientific or technological mind. The scientific mind is theoretically open to processing all new ideas. The technological mind tends to reject that which has not been statistically demonstrated. Thus the connotation of “philosophy” as an organization of vague or general thoughts about the meaning of life has often been antithetical to the technological mind of the twentieth century. However, some of our greatest scientists, including Einstein, spoke of the importance of ideas that are not yet statistically demonstrated.

Osteopathic philosophy is best described as a background reference system that identifies the nature of the patient, defines the physician’s mission, and establishes the basic premises of the logic of diagnosis and treatment. There remains in the general medical community, which has not been exposed to this organizing system, a poor understanding of exactly what is meant by osteopathic philosophy and why doctors of osteopathic medicine consider it important.

Osteopathic medical philosophy is centered on a profound respect for the inherent ability of the human being, and particularly the body, to heal itself. This philosophy has deep roots through recorded medical history. Over time, all ideas evolve as new information is discovered. Osteopathic philosophy is no exception: time has produced a distinction between classical osteopathy, which was taught by Still, and contemporary osteopathic medical philosophy, which integrates the basic elements of Still’s ideas with subsequent scientific discoveries (Box 17-1).

BOX 17-1 Traditional Versus Contemporary Osteopathy

Our Platform *

It should be known where osteopathy stands and what it stands for. A political party has a platform that all may know its position in regard to matters of public importance, what it stands for and what principles it advocates. The osteopath should make his position just as clear to the public. He should let the public know, in his platform, what he advocates in his campaign against disease. Our position can be tersely stated in the following planks:

First: We believe in sanitation and hygiene.

Second: We are opposed to the use of drugs as remedial agencies.

Third: We are opposed to vaccination.

Fourth: We are opposed to the use of serums in the treatment of disease. Nature furnishes its own serums if we know how to deliver them.

Fifth: We realize that many cases require surgical treatment and therefore advocate it as a last resort. We believe many surgical operations are unnecessarily performed and that many operations can be avoided by osteopathic treatment.

Sixth: The osteopath does not depend on electricity, X-radiance, hydrotherapy or other adjuncts, but relies on osteopathic measures in the treatment of disease.

Seventh: We have a friendly feeling for other non-drug, natural methods of healing, but we do not incorporate any other methods into our system. We are all opposed to drugs; in that respect at least, all natural, unharmful methods occupy the same ground. The fundamental principles of osteopathy are different from those of any other system and the cause of disease is considered from one standpoint, viz: disease is the result of anatomical abnormalities followed by physiological discord. To cure disease the abnormal parts must be adjusted to the normal; therefore other methods that are entirely different in principle have no place in the osteopathic system.

Eighth: Osteopathy is an independent system and can be applied to all conditions of disease, including purely surgical cases, and in these cases surgery is but a branch of osteopathy.

Ninth: We believe that our therapeutic house is just large enough for osteopathy and that when other methods are brought in just that much osteopathy must move out.

Contemporary Differences with “Our Platform”

Addressing each of the planks of the platform, today’s osteopathic physicians would have the following comments.

1. Hygienic and sanitary measures have, in fact, decreased mortality and morbidity in modern society far more than other medical measures.

2. Much of Still’s criticism of the medicine of his day was provoked precisely because it was not researched and therefore, to him, without logic and not scientifically valid. However, there have been only a very few osteopathic physicians, most of them at the end of the nineteenth or beginning of the twentieth century, who were completely opposed to all medicines. Contemporary medications are often overused; there may be a higher annual number of deaths caused by medication errors and side effects than are caused by highway accidents.

3. Immunization is now achieved with standard purified doses and is better understood. Statistics have demonstrated that the morbidity and mortality rates associated with not using immunizations are considerably worse than those found when immunizations are used. Although it is impossible to predict the outcome of immunization in an individual case, assuming that the patient who succumbs to an idiosyncratic reaction to a vaccine did not have that reaction because of the sensitivity to the medium (e.g., egg protein), that patient may be the one who would have had a similar or worse reaction to the disease in an epidemic if the population were not immunized.

4. Serums or other blood parts in Still’s day were much more dangerous than those found today. However, AIDS and other blood-borne diseases have demonstrated that body fluids, cells, and cell parts must be used with appropriate caution.

5. Surgery is necessary but may remain overused in the United States. Twentieth century medicine has improved diagnostic testing, and more conservative approaches have decreased the number of unnecessary surgeries. The use of aseptic technique, improved anesthesia, and microscopic and endoscopic surgery has diminished many negative consequences.

6. All therapies that are statistically demonstrated to aid patients are completely acceptable. Still was apparently never opposed to the use of x-rays studies for diagnostic purposes, because the ASO had the second diagnostic x-ray machine west of the Mississippi River. The use of radiation therapy as we know it was unknown in his time, as was the use of lasers for therapeutic purposes.

7. We recognize that disease has multiple causes that were unknown in Still’s day (e.g., genetic abnormality, nutritional deficiencies, radiation damage [including sunlight], psychosomatic effects) and that his unifactorial description of the cause of illness is no longer tenable.

8. The therapeutic house of the osteopathic profession, except for a few of its founding members, has always included the latest of research on medications and the expansion in medical knowledge through this past century. However, the incorporation of this expanded knowledge into medical school curricula has resulted in less available instructional time for osteopathic manipulation, leaving some physicians less skilled and neglecting its use in appropriate cases.

^* “Our Platform” from Korr IM, Ogilvie CD: Health orientation in medical education, U.S. The Texas College of Osteopathic Medicine, Prev Med 10:710, 1981.

Classical Osteopathic Philosophy

Classical osteopathic philosophy identifies the human being as a trinity, including body, mind, and spirit. However, Still speaks in his writings very little about how to deal with the spirit or mind, leaving that up to the individual, and confines himself in general to dealing with the body. The osteopathic perspective is that the body is a marvelous machine that will function perfectly if the structure is perfect. If a patient is sick but his body has sufficient recuperative power, the anatomy can be adjusted to the structural ideal, which assists a return to normal physiology. Surgery and obstetrics are included in this philosophy. Interestingly, Still believed that the diet of his time (completely organic in that era) was sufficient and that the body (the machine) could handle any fuel as long as the machine was working correctly.

The triune nature of the human being that Still so often mentioned dates back to at least the Greeks and probably to the Egyptians. The body is obvious and needs no further definition. The mind, however, has been described both as an epiphenomenon of the brain and its biochemistry and as something that is more than the product of chemical interactions. Emotions are generally identified with the mind, but does a third factor actually exist? Although science openly questions the existence of spirit, it is perhaps easiest to say that throughout history, a possible third factor of human existence has been universally recognized by human societies. This factor is sometimes regarded as the most potent but the most unpredictable. Although osteopathic philosophy recognizes this factor and respects it, Still did not spend a lot of time on this interesting question in his writings or medical practice.

Still focused on what could be seen and demonstrated, particularly on the relations between structure (anatomy) and function (physiology). His methods included taking a history, observing and palpating the body, and adjusting the body’s constituent parts so that they were in normal positions, with normal motion, thereby promoting normal physiology. At that point, the innate self-regulating powers of the body would accomplish what was necessary for healing to take place. Surgery and obstetrics were considered to be a normal part of osteopathic practice. Thus, Still in his writings presents osteopathic philosophy as depending on science, and not on the idea of vitalism.

Evolution of the Osteopathic Philosophy

All philosophies that survive must be capable of incorporating newly discovered information. Striking differences from Still’s original platform are found in contemporary osteopathic medical philosophy and practice.

Still died in 1917. But by 1911, while he was still alive, the ASO had incorporated instruction in vaccines, serum therapy, and antitoxins into the bacteriology course (Trowbridge, 1991). Also by 1911 the first modern antibiotic, the arsenic compound Salvarsan, which had been developed by Paul Erlich, had been successfully used against syphilis (infection with Treponema pallidum) (Singer et al, 1962). Following the success of Salvarsan, the sulfa drugs were developed by the 1930s. As new medicines were created and researched, the faculty and students at the ASO and other osteopathic medical colleges adopted and used them. By the 1930s, the osteopathic philosophy had been expanded to include medicines that had proven their value through research, as illustrated in the following introductory quote from the 1935 edition of the “Sage Sayings of Still”:

Osteopathy is not a drugless therapy in the strict sense of the word. It uses drugs which have specific scientific value, such as antiseptics, parasiticides, antidotes, anesthetics or narcotics for the temporary relief of suffering. It is the empirical internal administration of drugs for therapeutic purposes that osteopathy opposes, substituting instead manipulation, mechanical measures and the balancing of the life essentials as more rational and more in keeping with the physiological functions of the body. The osteopathic physician is the skilled engineer of the vital human mechanism, influencing by manipulation and other osteopathic measures the activities of the nerves, cells, glands and organs, the distribution of fluids and the discharge of nerve impulses, thus normalizing tissue, fluid and function. (Webster, 1935)

Antiseptic surgical technique was developed at about the same time as osteopathy and was included in surgical procedures practiced by the new profession. One difference between the allopathic and osteopathic approaches was that patients received OMT before and after surgery. Postsurgical treatment focused on soft tissue manipulation and rib raising, an articulatory treatment designed to increase the efficiency of breathing while calming the sympathetic nervous system.

The development of the sulfa antibiotics (and their increased use in hospitalized patients in the 1930s) and the advent of penicillin (as noted earlier, developed in 1927 but not commercially available until after World War II in 1945) significantly changed the practice of all medicine. Except for a very few older DOs who believed manipulation was the only answer, osteopathic physicians adopted these “miracle” medicines immediately. By accepting the use of thoroughly researched, effective medicines, classical osteopathic philosophy expanded to a more comprehensive contemporary osteopathic medical philosophy.

As an indication of the evolution of osteopathic thought, George W. Northup, DO, was quoted in 1996 as saying the following:

It is now better understood that a given “disease” is not so easily defined as was once believed. The search for a single cause for a single disease has produced disillusionment. Even the “germ theory” is not sufficient to provide a “simple” explanation for infectious diseases. All of us live in a world of potential bacterial invasion, but relatively few become infected. There are multiple causes, even in bacterially induced diseases. Disease is a total body response. It is not merely a stomach ulcer, a broken bone, or a troublesome mother-in-law. It is a disturbance of the structure-function of the body and not an isolated or local insult. Equally important is the recognition that disease is multi-causal. The understanding that multiple causes of disease can arise from remote but interconnected parts of the body will ultimately emerge into a unifying philosophy for all of medicine. When this occurs, it will embrace many of the basic principles of osteopathic medicine.

The shift in osteopathic thought embraced the progress of the scientific development of medications in the twentieth century but maintained the belief that it is not the physician who heals, but the body itself, which heals through its homeostatic mechanisms. Contemporary osteopathic medical philosophy also maintains a belief in the efficacy of manipulation to diminish or eliminate pain, improve motion, and decrease physiologic and sometimes psychological stress, thereby helping the body regain optimal homeostatic levels.

Still’s original opposition to the medication of his time was due to their obvious negative effects and the lack of research to support them. One of his better-known quotes is, “Man should study and use the drugs compounded in his own body” (Still, 1897). This is increasingly the method of study today: finding out how the body works and then using medicines that interact with the body’s cellular receptors and that mimic or, in some cases, are identical to the compounds found in the body.

Contemporary Osteopathic Medical Philosophy

The official definition of the term osteopathic philosophy at the start of the twenty-first century, published in the “Glossary of Osteopathic Terminology” section of the AOA Yearbook, 2000, is the following:

Osteopathic philosophy: Osteopathic medicine is a philosophy of health care and a distinctive art, supported by expanding scientific knowledge; its philosophy embraces the concept of the unity of the living organism’s structure (anatomy) and function (physiology). Its art is the application of the philosophy in the practice of medicine and surgery in all its branches and specialties. Its science includes the behavioral, chemical, physical, spiritual and biological knowledge related to the establishment and maintenance of health as well as the prevention and alleviation of disease. (American Osteopathic Association, 1998)

Osteopathic concepts emphasize the following principles (American Osteopathic Association, 1998):

1. The human being is a dynamic unit of function.

2. The body possesses self-regulatory mechanisms that are self-healing in nature.

3. Structure and function are interrelated at all levels.

4. Rational treatment is based on these principles.

Contemporary osteopathic medical philosophy begins with classical osteopathy and integrates additional knowledge. Rather than application of the choice either/or to manipulation or medicine, both/and is often more appropriate. Other evolved changes include recently developed knowledge of nutrition, exercise, environmental factors, genetics and molecular biology, neuroimmunology, and psychology.

For instance, nutrition is now considered important. Still did not consider it significant and often recommended that patients just “eat what they want of good, plain nutritious food” (Still, 1897). The importance of nutrition was later added to Still’s original philosophy because, although Still commented on avoiding fad diets, the food Americans ate in his age was very different from the average American diet of our times (see Chapter 25). During Still’s lifetime all crops were grown organically, by definition, and most of the population of the United States was still in a rural environment. Although he mentioned good food several times, he assumed that the average diet of that era was sufficient for nourishment.

For exercise, Still occasionally mentioned walking or horseback riding. In the preautomotive society of his time, there was little need to recommend these—all people in the United States walked or rode horseback to get where they were going. A great many labor-saving devices had not yet been invented, so normal daily living took care of most of the exercise needs of the population.

Likewise, the dangers of excessive solar radiation to health had not yet become apparent in a society in which tanning was not considered attractive, sun exposure being more commonly experienced as a “red neck” than as a Hollywood tan (see Chapter 11). Farmers often wore long-sleeved shirts and hats, and even swimsuits provided practically full covering of the body and, for women, were paired with a parasol (meaning literally, from the Spanish, “against the sun”) for protection from the sun. Air pollution, water pollution, and noise pollution were not specifically identified as causes of illness, nor were workplace toxins. Radiation damage was undiscovered. However, there was a general sense that densely populated, dark, dirty urban environments were unhealthy, which led to the “nature cure” and the “west cure” meant to provide benefit from exposure to recreation in the wilderness away from civilization (see Chapter 1).

Genetic mutations and deficiencies also were unknown. Physicians were virtually ignorant of the science of genetics at the end of the nineteenth century. The current hopeful promotion of “biotech” research promises multiple benefits from our expanding knowledge of molecular biology. Although this knowledge has great potential for both good and harm, its application may also be seen to fit with osteopathic philosophy.

Mind-body approaches have shown considerable potential for patient applications. Biofeedback and the relaxation response have been validated by research as ways of manipulating homeostatic mechanisms to improve psychological, neurological, and immune system functions (see Section II of this book). Psychological counseling techniques have advanced the possibilities for patients to address the stresses in their psychosocial milieu.

All of these etiological factors of illness have accordingly been integrated into an expanding contemporary osteopathic philosophy while it has retained the profound respect for the body’s ability to function in the face of many challenges and its inherent capacity for self-healing when injury or illness is present.

Still thought the body was basically perfect as it was and could process environmental and nutritional input without damage unless there was an injury resulting in structural damage. We now know that the human organism is continuous with the environment, and on more than one level (body: physical; mind: thought and emotion; spirit: belief). Illness is seen by the twenty-first-century osteopathic physician as having multiple causes, any one of which can be the initiator or promoter. Nonetheless, all of these factors potentially affect the structure of the body, whether at a gross (neuromusculoskeletal) level or at a microscopic (stereochemical-bioelectrochemical) level.

Wellness therefore lies along a continuum with illness, across the time frame between the points of conception and death. Illness begins as wellness declines. Wellness indicates that the individual is capable of accepting multiple challenges without the decompensation of homeostasis to the point of interference with normal activities. As the system loses optimal homeostatic balance, less of an environmental-emotional insult is needed to precipitate a state of illness.

Early in the continuum lie problems such as nutritional deficiency, insufficient exercise or rest, and inappropriate levels of stress. If these problems are addressed while they are simple, the organism recovers and retains adaptability. On an overlapping or interactive continuum lies gross structural integrity through tensegrity, which involves bilateral muscle tone, balance, and function. This tensegrity system is also interactive with neural activity levels (especially in the autonomic nervous system), particularly as these factors affect the rest of the body through the respiratory, circulatory, lymphatic, endocrine, and immune systems.

When nothing is done, our homeostatic mechanisms may effect a recovery from illness without aid. Sometimes, however, the body does not have the ability to recover on its own. In such cases, structural dysfunction at either the gross or the microscopic level can be compounded by the sequelae of inflammation, pain, and tissue congestion. These negative changes in the biochemical environment of the body can cause many variables in the endocrine and immune systems to swing to wider extremes and destabilize one or more of the body’s systems, leading to illness. Simple problems can sometimes be solved with manipulation, lifestyle changes (e.g., exercises), or nutrition to reestablish optimal homeostatic set points.

Ideas such as these are not easily understood by a reductionistic approach to the body, in which each variable is analyzed by itself or perhaps in conjunction with one or two other variables (e.g., the balance between insulin and glucagon). Current understanding recognizes much more complexity in the interactions between many more subtle variables, such as homeostatic hormonal systems that control many body functions.

The use of a complex adaptive systems model, with chaos theory mathematics, has enabled greater understanding of the complexity of dynamic medical systems. Chaos theory mathematics allows us to understand how altering a single or even a few variables in one system (e.g., cardiovascular) can affect the function of other systems, and thereby the entire human being. One factor that has been noted is that a complex system has sensitive dependence on initial conditions. This concept has been popularized as the butterfly effect, which suggests that the simple motion of a butterfly’s wings in the Amazon may affect the weather patterns in Moscow 3 months later (Gleick, 1987). Although this extreme example may makes us chuckle, or marvel, the mathematical models following chaos theory principles appear to be closer to predicting what actually happens in the natural world than are any previous analyses. Mathematicians now use similar models to explain, for example, a decompensating cycle of cardiac arrhythmia leading to fatal fibrillation (Gleick, 1987). Understanding new concepts such as point attractors, strange attractors, triviality, nontriviality, and degeneracy leads to a better understanding of the processes of homeostasis and the way in which manipulation of anatomical relations and tissue tensions may promote physiological adaptability.

Each of the body’s systems is understood to be integrated with the entire body, functioning in a bidirectional manner as part of the whole person. The neuromusculoskeletal system is the largest single system in the body; it reflects the state of health of the other systems, yielding diagnostic clues for systemic or organic function or dysfunction. It can also be used as an access for treatment, using manipulation to change the motion possible at the joints and the set points of muscle length and tone, and thereby affecting vascular and lymphatic flow and neural (particularly autonomic) tone.