The specter that had haunted the Tufts Medical School ever since the Flexner Report of 1910 - that of losing its Class A rating - refused to disappear in the period after the First World War. President Cousens strove mightily to exorcise the specter, and the problem was a source of constant worry to him. The inflated enrollments of both medical and dental schools had been aggravated by the lengthening of their courses and by the establishment of pre-medical and pre-dental schools. Laboratory space had been at such a premium during the war that the first section of an Anatomical Building had been constructed during President Bumpus' administration, but only one-third of the structure had actually been completed and put to use when Cousens became president.

Dean Rushmore, Painter's successor, wrote letter after letter to President Cousens asking that the medical school be made less of a commercial operation and that the number of students be brought more realistically into line with the capacity of the school. What the medical school needed, in his estimation, was "improvement in the quality, rather than increase in quantity." The burden of fund-raising rested, in his opinion, on the Trustees of Tufts College, not on the teaching and administrative staff of the school. The dean remained unsatisfied with the continuing low percentage of medical students who had earned Bachelor's degrees, and put much of the blame on the existence of the two-year pre-medical course, which automatically reduced the number of students willing and able to pursue a four-year college course. Dean Rushmore was even less pleased to see the Trustees, instead of curtailing enrollment, vote another tuition increase, effective in 1925-26.[26] 

After Dean Rushmore had resigned from the deanship in protest against the College's medical school policies, Dr. A. Warren Stearns was selected to head the school. Stearns was himself a graduate of the medical school (Class of 1910) and had served in the Department of Neurology since 1921. By the mid-1920's he had already established a reputation as a leading criminologist. One of his areas of special activity was psychiatry, and he had served in numerous responsible positions in both private and public capacities. He was for a time medical director of the Massachusetts Society for Mental Hygiene and psychiatrist for the Massachusetts State Prison. During part of his tenure as dean he served as State Commissioner of Corrections. Dr. Stearns inherited a host of thorny problems when he assumed the deanship in September 1927. Increases in tuition seemed to have no effect on the large number of applicants; the entering class in 1928 (totaling 135) was selected from more than 1,200. While the school enjoyed apparently phenomenal prosperity in the 1920's, its very future nevertheless became a matter of serious and prolonged discussion.

The secretary of the Council on Medical Education of the American Medical Association had visited the medical school in 1926 and had not liked what he found. He told the College that certain recommendations would have to be carried out within two or three years. If they were not, the school would probably lose its Class A standing. The bill of particulars required the elimination of the pre-medical school, a separation of the medical school from the dental school, an increase in the staff of laboratory departments, the application of all revenues derived from medical school students to the expenses of the school, and the establishment of a special endowment. President Cousens sought a resolution of at least some of these problems by appealing again to the General Education Board. This, in turn, meant a reconsideration of the location of the medical school, which had become an item of Trustee business in 1925.

If the moving of the medical school were considered advisable, two possibilities were open. There was persistent talk that it might

It appeared in the winter of 1926 that Cousens' hopes had been carried a step nearer to realization. After an interview with Dr. Abraham Flexner of the General Education Board, the president obtained from the Executive Committee approval of a "general plan," yet to be formulated in detail, to move the medical school to the Hill and to construct buildings and a hospital. President Cousens also made arrangements, at the suggestion of Dr. Flexner, for a review by Dr. G. Canby Robinson, former dean of the medical school at Vanderbilt University and director of the Cornell University-New York Hospital Medical Center. Dr. Robinson, in a report made after a brief visit to the Tufts Medical School in the summer of 1928, recommended either that it be completely reorganized or that "Tufts College should retire from the field of medical education" and concentrate its efforts on dental education. As Dr. Robinson saw it, the wiser course for Tufts was to concentrate its efforts on collegiate education and to leave the field of professional education in medicine to be developed by other institutions unless it could acquire at least $13,000,000 to start anew. If this were possible, then the Medford campus would be the proper location. Even if the new hospital were eliminated in the new plan, the cost would remain over $5,000,000.

Dr. Robinson found the Tufts Medical School isolated, operating with antiquated buildings and equipment better adapted for high school instruction, with an impossibly large student body, and

The threat of the Council on Medical Education to reclassify the Tufts Medical School as a Class B facility was not scheduled to be carried out (if at all) until the spring of 1929. This gave the Trustees time to effect at least a few of the required changes. The closing of the pre-medical school was voted, and a few new appointments were made in the laboratory departments; this remedied somewhat a basic weakness, but it did not accomplish in any real sense the separation of the medical and dental schools. They continued to occupy the same quarters, and medical school staff still taught some dental school courses. Cousens was as blunt as he could be with his fellow Trustees. Tufts did not really have a first-class medical school, in his estimation, and he knew that the Trustees in their own hearts agreed with him, and they might as well face up to the facts. It was "in effect a Class B school . . . whether so labelled or not." A second-class medical school "in name as well as in fact could not be endured." Cousens proposed to solve the problem by following Dr. Robinson's compromise proposal of moving the school to the Medford campus, but without a new hospital, and at the same time paring down to the bone every cost estimate that was made. Cousens would have all but the clinical facilities located on the Hill and ready for use by the fall of 1930. Some kind of medical center, possibly with the Boston City Hospital at the core, could be provided, but would not be needed until the third-year class of the "new medical school" registered in 1932. The dental school would, under this plan, remain at the Huntington Avenue headquarters in Boston.

The president saw only two choices for the College; there was no "middle ground." Either the medical school had to be closed immediately, or Robinson's second proposal could be adopted so far as possible. The Trustees agreed and, like Cousens, elected to pursue the latter course. It was a difficult one to follow, for the long-sought and tantilizing offer of assistance from the General Education Board was abruptly withdrawn in 1928. Cousens attempted to obtain a definite commitment of assistance by presenting a detailed plan for the reorganization of the medical school along the lines recommended by Dr. Robinson, together with a request for $2,000,000. The president received a "flat refusal," on the ground that a reorganization of the General Education Board itself had resulted in a new policy that precluded direct aid to any medical school. Frustrated in this direction, Cousens snatched at another opportunity. A member of the Board of Trustees of the Boston Dispensary approached Cousens in the winter of 1928 and suggested that Tufts and the Dispensary might join with the Boston Floating Hospital in establishing a medical center.[28]  The three institutions could be the nucleus of a comprehensive unit that in 1929 was already being referred to as the "New England Medical Center." Plans were made for a campaign to raise $1,500,000 by March 1929. Tufts agreed to advance $65,000 toward its share of $500,000 in order to acquire land, build a hospital, and alter and enlarge the Boston Dispensary. The new facility was to be supervised by a Joint Administrative Board.[29] 

The "new Tufts Medical School" that Cousens and the Trustees had in mind was about to become a fact, although not in exactly the way it had been conceived. The improved clinical facilities would come first, and the removal of the rest of the medical school to Medford would have to wait. The new medical center presupposed an associated medical school. Here was Tufts' great opportunity. And while this exciting new prospect was being opened, the College complied with the "command" of the American Medical Association by releasing the contingency fund into which the profits of the medical school had been deposited and spending the money by reorganizing and strengthening the Departments of Physiology, Pathology, and Bacteriology. The start having finally been made, other improvements were scheduled but at a time when income and expense were almost in balance. Another increase in student fees was voted, effective in 1930-31. Tuition in the medical school became $400 - $100 higher than in the school of liberal arts and in Jackson College. There would be no difficulty in finding uses for the new income. Almost every paragraph of Dean Stearns' annual report for 1928-29 included the phrase "more personnel and equipment will be needed next year or in the near future." A Department of Psychiatry was created in 1930, and in the following year the school's offerings were greatly strengthened by the creation of the Department of Preventive Medicine through a grant from the Commonwealth Fund of New York which also provided a scholarship-loan fund for students. The fourth year was completely reorganized so that each student could serve the entire year under instruction at various hospitals for one-month periods. In 1931 two members of the medical school staff were given, for the first time, leaves of absence at full pay for research and study in Europe, on the recommendation of the Research Committee of the medical school.[30]  A new spirit and sense of purpose seemed to have been infused into the school.

Before the creation of the New England Medical Center in 1930, the medical school had also added new ties of various degrees of closeness with hospitals and clinics in the metropolitan area. Neither the ill-fated efforts to make Grace Hospital a permanent facility under the direct control of the medical school nor the Tremont Dispensary had given the school exactly what it needed and wanted.[31]  The first hospital actually to be staffed completely with Tufts medical personnel was the Evangeline Booth Hospital, which had been opened in 1920 as the Roxbury Hospital, to handle maternity cases. The clinical opportunities which it offered after association with Tufts in 1922 became invaluable for teaching obstetrics and pediatrics. Facilities of the new Beth Israel Hospital opened in 1928 gave Tufts students opportunities for instruction in such specialties as neurology, orthopedics, and gynecology as well as in general medicine and surgery. Teaching privileges in pathology were given to Tufts students for the first time in 1929-30 in the Massachusetts General Hospital, traditionally the bailiwick of the Harvard Medical School. Within a short time after the New England Medical Center was opened, valuable assistance from the outside was received. In 1931 the medical school received a grant of $50,000 from William Bingham of Bethel, Maine, who was particularly interested in developing rural medicine. This gift, like subsequent contributions by the Bingham Associates of $25,000 for X-ray equipment and maintenance, and an additional $25,000 for a hospital unit, was intended to strengthen the new Center. Part of the Bingham gifts was used to finance the work of Dr. Joseph H. Pratt, who served as Professor of Clinical Medicine from 1929 to 1947. By the fall of 1932 facilities were such that the amount of teaching in the Center was second only to that in the Boston City Hospital. Another important relationship was established when, in 1936, arrangements were made with the Carney Hospital that all the teaching there would be done by members of the medical school staff.

The continued excess of applicants of good quality even during the depression years prompted Dean Stearns to express the

The organizing of a graduate school of medicine was also discussed in the early 1930's. Nothing concrete was done at the time, but arrangements were made for post-M.D. work for short periods of study in nearly all subjects. A decade later (in 1943-44), graduate study in the medical sciences was made available through the cooperation of the medical school for students who were not candidates for a medical or dental degree.[34] 

The Tufts Medical School took two important strides in the 1930's - one forward and one backward. The creation of the New England Medical Center was a most welcome event. Not at all welcome was the action of the Council on Medical Education and Hospitals of the American Medical Association in 1935. On the recommendation of an inspection team which visited the school, it lost its Class A rating and found itself on probation. The fact that it was one of nine schools receiving such treatment was no comfort at all. Even less comforting was the realization that, in coming to its decision about the Tufts school, the Council listed not a single criticism that had not already been made repeatedly. The student body was entirely too large; the pre-clinical

Cousens immediately informed the Council that the College not only was aware of all these (and other) deficiencies, but with isolated exceptions had already undertaken to remedy them. The quota of entering students had been reduced for future classes. A campaign to secure a special endowment was already in the process of organization. Plans for adding a third story to the Anatomy Building were being "definitely developed."[36]  He explained that the delay had been caused by the prolonged discussions over whether or not to move the entire plant to the Hill. The departments, Cousens told the Council, were being strengthened one by one by additional staff. Improvements had already been made in the Department of Physiology (which had fared relatively well at the hands of the inspection team), and the Department of Anatomy was receiving special attention. The inspectors had been disturbed to find that the bacteriological laboratory was being supervised by a person with the rank of assistant professor who did not possess even one academic degree. Cousens hastened to defend the appointment, explaining that it was only temporary while the regular teacher was on leave of absence to study at the University of London, but that in any case the person in question was

The medical school had apparently reached another crossroads. Cousens categorically refused to countenance the possibility of operating a Class B school and just as stubbornly refused to discontinue it, on the grounds that such a step would mean even more than the dislocation of the entire structure of the College. As the president saw it, "the Tufts Medical School is not merely the concern of the Trustees and alumni of Tufts College, but its future is of consequence to the whole of New England." Dean Stearns, with the criticisms of the Council on Medical Education at hand, reviewed the strengths and weaknesses of the school at some length and was frank to concede that the majority of the adverse comment was justified. He was not happy to see an increasing number of failures of Tufts medical students on state and national Board examinations but considered the trend an outgrowth of the philosophy on which the school was being operated and not necessarily the result of poor teaching and overcrowded laboratories. He defended the emphasis on clinical experience rather than "pedagogy" during the third and fourth years. The staff and administration had stood from the beginning on the ground that the primary function of the school was not to operate "as an isolated institution whose sole function is to train a selected group of students to the highest degree possible in the scientific aspects of medicine." Its basic task was to meet the practical medical needs

[25] The inspection was conducted by Dr. N. P. Colwell in the fall of 1920 after consultation with Flexner, who represented the Rockefeller Foundation, and Wallace Buttrick, who represented the General Education Board. Dr. Colwell's report was generally favorable. One possibility discussed at length by Cousens and Buttrick was to secure the services of Dr. Thomas A. Storey, head of the United States Interdepartmental Social Hygiene Board in Washington, D.C., and subsequently on the staff of the College of the City of New York. Storey would replace Dr. Painter, who had resigned as dean of the Tufts Medical School in 1921. Storey's salary would be paid by the Board while it was engaged in a comprehensive review of medical education in New England, in which the Tufts school would have played a major part.

[26] The tuition became an inclusive fee of $300, which meant actually a net increase of $50. Rushmore had been so upset by the conditions in the medical school, and particularly the Trustees' policy of siphoning off medical school profits to other parts of the College, that he submitted an undated resignation to Cousens after having been in office less than two years. He was prevailed upon to remain as dean until 1927.

[27] This criticism was met, at least in part, when a new accounting procedure was established in the treasurer's office in 1928-29 by which deficits from the operations of any of the schools were considered as general College expense and charged on a per capita basis against those parts of the institution operating at a profit. Whatever net surplus remained was made available for divisions showing a deficit.

[28] The Boston Dispensary, dating back to 1796, was originally intended to provide home medical care for the poor. By 1930 it had expanded its operations to include diagnostic clinics for ambulatory patients and extensive laboratory facilities for training technicians in several specialties. The Boston Floating Hospital for Infants and Children was founded in 1894 by the Rev. Rufus Tobey. It started aboard a rented excursion steamer that was towed around Boston Harbor by a tug and was intended to give ailing children in the city an opportunity to enjoy fresh air. Funds were later raised to construct a steamer equipped especially for the care of sick children. The "floating hospital," placed in service in 1905, lasted until 1927, when it burned at the dock shortly after having been overhauled. Land-based permanent hospital facilities were developed in Boston between 1929 and 1931. The hospital became an important research unit for the study of pediatrics.

[29] The state legislature approved the creation of the medical center on February 13, 1930, and the College charter was amended accordingly. Acts and Resolves, General Court of Massachusetts, 1930, Chapter 40.

[30] They were Dr. Attilio Canzanelli and Dr. Benjamin Spector, at the time Instructor in Physiology and Associate Professor of Anatomy, respectively. Grants for medical research for both students and faculty were also made possible in the 1930's through income from the trust estates of Earle Perry Charlton of Fall River, Massachusetts, which became available to the College after prolonged litigation.

[31] For a summary of the major facilities available to the medical school, see Benjamin Spector, A History of Tufts College Medical School, pp. 317-326. The Tremont Dispensary and the Massachusetts Dispensary for Women were taken over by the medical school in 1924.

[32] In 1931-32, 85 in the first-year class of 127 held college degrees.

[33] Tuition was raised from $400 to $500 to help compensate for the resulting loss of revenue. Tuition in the dental school was raised, effective the same date, from $350 to $400.

[34] Persons wishing to earn the M.S. degree in one of seven medical sciences could do so by meeting the same requirements as for the degree in the natural sciences. Courses could be taken both in the science departments on the Hill and in the medical school. The work was to be administered under the general supervision of the graduate school faculty.

[35] No real attempt had ever been made to establish a comprehensive or definitive collection because of the accessibility of the Boston Medical Library, to which Tufts made periodic token contributions. The combined medical-dental library, housed in the main building of the school, was serviced by a full-time librarian by the 1920's but had never received generous appropriations.

[36] The addition was authorized by the Trustees in the fall of 1935, but plans were revised in the following year to create additional space for the bacteriology laboratory by remodeling the amphitheater rather than building the third story.