Two Pathways

An ocean away: The story of how osteopathy crossed the Atlantic

Around the world, nonphysician osteopaths practice manipulation. Here’s how the trend got started.


When Andrew Taylor Still, MD, DO, developed osteopathy in the 1870s and 1880s, he hoped his new discipline would replace many of the prevailing medical practices of the time in the U.S., which included bloodletting, blistering and giving patients arsenic and mercury to “kill” the disease in their bodies.

In 19th-century America, the public didn’t hold physicians in high esteem, notes Jason Haxton, the director of the Museum of Osteopathic Medicine in Kirksville, Mo. An estimated half of all patients who visited a physician would die, sometimes from the treatment itself.

At the time, many practicing physicians had never been to medical school but simply apprenticed with a physician for several months.

“Most of the medical schools that were established in the U.S. in A.T. Still’s time were on the East Coast,” says Raymond J. Hruby, DO, a professor of osteopathic manipulative medicine at Western University of Health Sciences College of Osteopathic Medicine of the Pacific (WesternU/COMP) in Pomona, Calif. “As people progressed to the Midwest and the West, there weren’t as many medical schools in those areas. And even on the East Coast, it was still very common for people to become physicians by apprenticeship rather than going to medical school. That was an equally acceptable pathway.”

Physicians who attended medical school back then weren’t necessarily better educated than apprentices. Many medical schools in that time were little more than for-profit degree mills where students were decreed physicians before they even worked on cadavers, Haxton says.

“Imagine having your appendix cut out by a physician who had never even cut into a dead body, let alone a live one,” he says. “Of course you’re going to have mistakes and infections.”

This is the medical landscape osteopathic medicine entered—a public disenfranchised with medicine, half of all patients dying, inexperienced physicians performing surgery. The messy state of U.S. health care left a door open for osteopathic medicine, Haxton says, because it was less invasive and Dr. Still’s techniques weren’t life-threatening.

The promise of a new form of medicine brought people from all over the world to Kirksville, often those who felt conventional medicine had failed them. One of these early visitors was John Martin Littlejohn, PhD, DO, MD, a Scottish academic who went on to establish the first school of osteopathy in Europe, which helped pave the way for the development of the European model of osteopathy.

Having been established in England a century ago as a manipulation-only discipline, separate from conventional medicine, osteopathy as an academic discipline spread from England to mainland Europe and British territories such as Canada and Australia.

While DOs have full medical practice rights in more than 65 countries, only in the U.S. are graduates of osteopathic medical schools fully licensed physicians. In other countries, graduates of osteopathy schools typically only perform manipulation on their patients. In many of them, osteopaths aren’t regulated or licensed.

How did these two different paths of osteopathic medicine develop, and why? Haxton says the answers lie in Dr. Littlejohn’s career path and the vastly different medical climates of the U.S. and Europe during that time period.

Dr. Littlejohn’s journey

Dr. Littlejohn moved to the U.S. in 1892 and pursued a PhD at Columbia University in New York City. He subsequently was appointed president of Amity College, a small liberal arts school in College Springs, Iowa, and sought treatment from Dr. Still in 1897 for a throat condition, according to the textbook Foundations of Osteopathic Medicine.

Amazed by Dr. Still’s work, Dr. Littlejohn quit his comfortable, secure post to move to Kirksville and study osteopathy. Dr. Littlejohn began teaching physiology at the school while he was still a student, and in 1899, he became the faculty dean of Dr. Still’s school, the American School of Osteopathy, now called the A.T. Still University-Kirksville College of Osteopathic Medicine.

However, Dr. Littlejohn’s tenure in Kirksville was short-lived. He had brought on his two brothers, James Littlejohn, MD, DO, and David Littlejohn, MD, DO, as faculty, and the three began to have disagreements with Dr. Still. At the root of the discord was the Littlejohns’ vision for osteopathy. Dr. Littlejohn and his brothers wanted to integrate osteopathic medicine within a conventional medical curriculum, while Dr. Still saw no reason to blend the systems.

In September of 1899, Dr. Still appointed Arthur Grant Hildreth, DO, as senior dean of the American School of Osteopathy over Dr. Littlejohn, who was better educated and had already been a college president. Dr. Hildreth was a local, had known Dr. Still for many years, and was a member of the school’s first class. The Littlejohns opposed Dr. Hildreth’s appointment because they felt he didn’t have sufficient education to serve as dean and they also disagreed with Dr. Hildreth’s views of osteopathy, which were more aligned with Dr. Still’s, Haxton says.

The Littlejohns resigned from the school within a few months.

Across the Atlantic

In 1900, Dr. Littlejohn and his brothers relocated to Chicago and established the American College of Osteopathic Medicine and Surgery, which has since become the Midwestern University/Chicago College of Osteopathic Medicine in Downers Grove, Ill. Disagreements among the three brothers led to them parting ways in 1913, Haxton says. Ownership of the school was transferred that year to another group of DOs, according to Midwestern University spokeswoman Karen D. Johnson, PhD. Dr. James Littlejohn stayed at the school as a faculty member, and Dr. David Littlejohn practiced medicine in the Chicago area, Haxton says.

Dr. John Martin Littlejohn returned to Britain, where he had been lecturing on osteopathy during visits around the turn of the century, and settled in London. In 1913, on the cusp of World War I, some U.S.-trained osteopathic physicians were practicing in England, many of them native Brits. The country, however, had no osteopathic medical schools. Dr. Littlejohn wanted to change that, so he established the British School of Osteopathy (BSO) in 1917, the first osteopathic institution in Europe.

Dr. Littlejohn intended to set up a school that integrated osteopathy with conventional medicine. But he faced opposition from the British medical establishment, which was older and more tightly regulated than the U.S. medical system, says Jane E. Carreiro, DO.

“When Littlejohn got to England, there was a lot of resistance to licensing another group of clinicians or even training them in a way that gave them the same sort of experiences that physicians had,” says Dr. Carreiro, who is a professor of OMM at the University of New England College of Osteopathic Medicine in Biddeford, Maine, and a former president of the American Academy of Osteopathy.

European physicians were more scientifically advanced than those in the United States, notes WesternU/COMP’s Dr. Hruby, who is a fellow of the American Academy of Osteopathy. Europeans were less open to a different form of medicine because they believed what they already had was sufficient.

“In Europe, they’d gone through the Middle Ages and the huge plagues, and the germ theory had been established,” Dr. Hruby says. “The microscope had been invented. And a lot of that stuff hadn’t transpired across the ocean in the U.S. yet. They were a little bit ahead of us.”

Trainees of the British School of Osteopathy were denied access to hospitals, dissection labs and other key components of physician education, according to Foundations of Osteopathic Medicine. So osteopathy began in Britain as an unlicensed, manipulation-only discipline.

Ironically, it was Dr. Littlejohn who had tried to persuade Dr. Still to expand osteopathy to include conventional medical techniques, yet he went on to lead a manipulation-only school. Conversely, Dr. Still wasn’t interested in expanding osteopathy beyond manipulation in its early days, but that’s exactly what happened to osteopathy in the U.S.

In 1910, the Flexner report, a critical evaluation of U.S. medical schools, tilted the debate within the profession in the U.S. of whether to pursue a full medical model or stick to manipulation.

“The Flexner report came through, saying to various schools, ‘You’re not safe, you’re not safe, you’re not safe. Close them all,’ ” Dr. Carreiro says. “In the reshuffling, what emerged was a training program that looked more like what the allopathic schools had.”

In the aftermath of the Flexner report, the elimination of as many as 100 medical schools provided osteopathic physicians with a solid niche in rural, underserved communities, Haxton says.

How osteopathy evolved in Britain

But in England, with BSO graduates limited to manipulation, the discipline developed quite differently.

In the 1930s, Viscount Elibank Gideon Oliphant-Murray, a member of the British nobility who was fond of osteopathy, attempted several times to establish an act of Parliament allowing for the self-regulation and recognition of the profession, which would prevent untrained persons from calling themselves osteopaths. Oliphant-Murray never succeeded, and Dr. Littlejohn, who testified in at least one hearing, may have contributed to the act’s demise. According to a 1935 report from the House of Lords committee overseeing the legislation, the committee members questioned the validity of Dr. Littlejohn’s degrees. Their skepticism may be part of the reason that the act didn’t pass. Eventually, a House of Lords committee recommended that the osteopaths set up a voluntary register of qualified practitioners, which they did.

“In 1939, the General Council and Register of Osteopaths was opened,” says Simon Fielding, a British osteopath and former special adviser to the U.K. Department of Health. “That ran as the main voluntary register in the U.K. for many years. But there was no protection of title or function, so people could in theory get osteopathic qualifications through correspondence or short weekend courses. The public had no real way of knowing who was a properly qualified osteopath.”

Osteopathy continued in this way, unlicensed and unregulated, for many years in the U.K. Manipulation-only osteopathy spread to some European countries, as well as Canada and Australia.

In the 1970s, Fielding had become frustrated by the lack of respect for osteopaths. He initiated a new effort to obtain government recognition and statutory regulation of the profession.

After a series of meetings over many years between Fielding and Britain’s General Medical Council and other medical groups, Parliament passed the Osteopaths Act in 1993. Fielding was the chief architect of the act and served as the first chairman of the new General Osteopathic Council (GOsC), a regulating body established under the act.

“The Osteopaths Act is legislation on the same basis as medicine and dentistry,” Fielding says. “So we have independent statutory self-regulation. We are not state-registered. It’s possible for doctors to refer patients to osteopaths. There’s then a transfer of clinical responsibility and an acceptance that we are diagnosticians in our own right.”

The act required U.K. osteopaths to register with the GOsC and demonstrate their competence. In subsequent years, new osteopaths who graduated from a GOsC-recognized program were admitted to the register. Fielding says the osteopathic profession in Britain came into its own after the act passed.

“The act helped to elevate the status of the profession in the eyes of the wider world,” he says. “And it also gave the osteopathic profession much more confidence in itself.”

The next potential milestone on the horizon for British osteopaths, Fielding says, is the right to prescribe medicine.

“It’s a controversial subject because we are by definition a profession that uses osteopathic manipulative treatment,” he says. “It’s the raison d’être of our work. But many in the profession believe it would be helpful to have some prescribing rights. It will probably happen over the next few years.”

A lack of prescribing rights is one of the major distinctions between practitioners of U.K. osteopathy and U.S. osteopathic medicine. Many osteopaths, however, find the limited rights to be beneficial.

“British osteopaths are not constrained by medicine,” says Marina Urquhart-Pullen, a British osteopath and the president of the British Osteopathic Association. “And for the most part, we’re not constrained by insurance companies. We try to keep true to the principles and philosophy of osteopathy without it being medicalized. Our osteopathy is very much based on good diagnosis, good listening and what we can do with our hands.”

British osteopathy has also evolved in the U.K. to favor slightly different techniques than those prevalent in the U.S., Fielding says.

“In Europe, there tends to be much more use of traditional osteopathic techniques,” he says. “Some practitioners will use quite a lot of the techniques that Littlejohn taught way back in the 1920s.”

What DOs and British osteopaths share

Despite their differences, DOs and British osteopaths share a dedication to holistic healing and whole-patient care. And many DOs are just as passionate about OMT as British osteopaths are. Fielding advises DOs to make the most of their OMT skills because he sees OMT becoming increasingly important in health care in the U.S. and around the world.

“With the exponential rise of chronic disease and the increasing failure of our health systems to manage it, the osteopathic profession, using OMT, can make a very important contribution in the coming years in managing these chronic diseases.”

Urquhart-Pullen says she would like to see greater cooperation between physicians—both allopathic and osteopathic—and osteopaths.

“I don’t like to see this division between medicine and osteopathy,” she says. “I don’t like to see it in the U.K. or in Europe, and it would be nice as well not to see it between the countries. People who trained as doctors sometimes consider their work superior to that of osteopaths, and osteopaths often think of themselves as a totally separate entity. Yet we’re all working toward the health of the patient and are using the best methods and mechanisms that we can.”


  1. John O'Brien MA DO

    Much of Littlejohn’s biography is surrounded by controversy. Its narrative and analysis is much more interesting than Jason Haxton describes. His own contribution during his time in Chicago (1900-1913) was provoking, especially his ideas away from the osteopathic spinal lesion as outlined by E S Comstock (JAOA 1910). My own research on J Martin Littlejohn suggests a complicated individual who eventually wavered whilst experiencing rejection from his colleagues. Had he continued to defend his principles of Adjustment and Adaptation who knows how the profession might have evolved both in America and Europe. Contrastingly,the Flexner experiment eventually led our American colleagues to follow their MD counterparts in 1935, an inevitable pathway towards proximity of both parties. That is beside the point, an interesting article, well done.

  2. Matt Snowdon

    What are the letters of professional designation that osteopaths are granted in non-US countries? For example, UK, France, Canada, Spain, Australia, and New Zealand? What other countries have schools of osteopathic medicine for becoming a fully practicing osteopathic physician?

  3. Why not MD,DO

    “What are the letters of professional designation that osteopaths are granted in non-US countries? For example, UK, France, Canada, Spain, Australia, and New Zealand? ”

    It is still DO in other countries. If MD, DO was good enough for AT Still, It should be good enough for US Osteopathic physicians today, right? The DO degree meaning different things in the US vs other countries just causes confusion among the general public and makes life harder for everyone. 99% of my curriculum is the exact same as MDs…I receive ~ 1.5-2 hours of OMM a week. It makes no sense.

    “What other countries have schools of osteopathic medicine for becoming a fully practicing osteopathic physician?”


  4. MC McGrath PhD(Otago. anat), DO(UK)

    The ‘professional designation that osteopaths are granted in non-US countries’ – for Australia and New Zealand as follows, where there is mutual recognition for board registered osteopaths who practice notionally as ‘allied healthcare’ under a limited license of practice and cannot prescribe drugs, nor perform surgery, nor sign death certificates, nor possess hospital admission rights, nor authorize work sickness certification, nor do anything beyond practice OMT much as has been done unchanged for a century. In NZ, the Osteopathic Council is on record as seeing no place for the prescription of drugs. Osteopathy and ‘evolution’ have yet to flower beyond an oxymoron.

    Tertiary qualifications in Australia and New Zealand required for registration to practice osteopathy.

    1. Royal Melbourne Institute of Technology University:
    Bachelor of Applied Science (Completmentary Medicine – Osteopathy).
    Master of Osteopathy.

    2. Southern Cross University, Lismore, NSW:
    Bachelor of Clinical Sciences (with a double major — Osteopathic Studies/Human Structure and Function).
    Master of Osteopathic Medicine.

    3. Victoria University, Melbourne:
    Bachelor of Science (Clinical Sciences).
    Master of Health Science (Osteopathy).

    4. Unitec, Auckland, NZ.
    Bachelor of Applied Science (Human Biology).
    Master of Osteopathy.

    As a footnote, those practitioners who qualified in the UK prior to 1990 (Diploma in Osteopathy) are now no longer deemed to hold a ‘registrable’ qualification in the UK. If such practitioners remain in Europe and wish to return and practice in the UK they may do so by virtue of a European Directive. If such a practitioner resides outside Europe (Australia or New Zealand for example) they are bizarrely required to undertake a very expensive programme that could enable them to gain a registrable qualification.

    MC McGrath (2013) ‘From distinct to indistinct, the life cycle of a medical heresy. Is osteopathic distinctiveness an anachronism?’
    International Journal of Osteopathic Medicine. Volume 16, Issue 1 , Pages 54-61.

  5. Rose Raymond

    Hi Matthew,

    I posed your questions to Josh Kerr, the AOA’s director of international affairs. He says:

    “Many countries including the U.K., Australia and New Zealand (where the profession is regulated) have moved to bachelor, master and even doctorate degrees in osteopathy, so those grads would have BA(osteo), BS(osteo), MA(osteo) or PhD(osteo) degrees. However, older osteopaths in these countries still have the Diploma of Osteopathy (DO) degrees.

    There are no other colleges of osteopathic medicine as they exist in the U.S. But in addition to the schools of osteopathy mentioned above, some countries such as Germany, France and Switzerland do have osteopathic training for MDs following their medical degrees, similar to taking a residency in OMT.”

    Thank you,

    Rose Raymond

  6. Stiofan Mac Suibhne

    I would like to correct Dr McGrath’s misinformation regarding the Osteopathic Council of New Zealand (OCNZ) prescription drugs and assessment of overseas trained osteopaths.

    As the statutory regulatory authority for the NZ osteopathic profession the OCNZ determines scope of practice for the profession, however it is not within the gift of the OCNZ to extend prescription rights to osteopaths. Decisions on prescribing rights rest with the Minister of Health.

    If the legislative framework were to change and osteopaths were to seek prescribing rights there would need to be a significant change in the training osteopaths undertake. OCNZ has never made any publics utterances on the place of prescribing in osteopathy. He may have misunderstood that within the powers granted to us by legislation, that is to determine scopes of practice, prescribing could not reasonably be included in the general scope of practice of all osteopaths. To do so would be to grant prescribing right to those that had not undertaken appropriate training. If prescribing rights were extended to osteopaths an extended scope of practice would be determined with an accredited qualification. Only these individuals would then have the right to prescribe.

    The OCNZ does not currently offer assessment of overseas qualified osteopaths other than those that hold a recognised qualification accredited by the UK General Osteopathic Council. This class of individuals may apply for registration and complete a year’s long work asked competency programme evidence by a portfolio. OCNZ is currently investigating the development of assessment processes to assess osteopaths with a variety of educational biographies and may well offer an other assessment pathways in the near future.

    Stiofan Mac Suibhne, Co-chair OCNZ

  7. Pingback: Osteopathy: History, Principles and Treatment. – The freaky student

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