The dean of the Tufts Medical School had reported with some pride in 1903 that, with a teaching staff of 105 and an enrollment of 403 students, the school was the largest such institution in New England. By 1906 the school was seventh in size of the 175 medical schools in the United States. Enrollment in both medical and dental schools had climbed steadily in the years preceding the First World War. There seemed to be nothing to hinder their growth. The opening of new buildings for the Harvard Medical School in 1905-6 close by the Tufts schools was acknowledged to be an important event in medical education but was considered no threat to Tufts, for Harvard's principal efforts were aimed at research, while

However, quantity and quality are not always synonymous, and some individuals concerned with the medical school could not shake off the nagging feeling that the large enrollments might be due to low admission standards as well as the attractiveness of the school's teaching facilities and professional stature. Likewise, lack of endowment, difficulties inherent in employing a largely part-time faculty, and the failure to obtain a hospital for exclusive Tufts use raised questions and created problems that refused to be downed. The first of many calls for endowment to finance clinics, laboratories, research, and a hospital connected with the school had been heard within two years of its establishment. A member of the medical faculty, in an article in the Tufts College Graduate, had called attention also to the lack of scholarship aid. "The department at the Hill boasts of about seventy scholarships, while the medical department . . . has not a single scholarship or other endowment of any sort." Plans were made to launch a drive for endowment funds for the medical school as part of the celebration of the semicentennial of the College in 1905, but nothing of great significance was accomplished. The first important endowment for research was made in 1908, when Herbert L. and Mary Crane Johnson established a fund in memory of their daughter Elizabeth, who had died of streptococcus meningitis. The five-year grant ($1,000 each year) was made to Dr. Timothy Leary to aid in the discovery of antidotes and possible cures for streptococcus infections. It greatly aided the work already undertaken at the medical school in the field of serum and vaccine development.

When a petition was granted by the state legislature in 1901 to remove the ceiling on annual income receivable by the Tufts Corporation, a petition was also granted to allow the College "to establish and maintain a hospital." The hope was expressed repeatedly that a hospital might some day be acquired. One member of the medical faculty suggested in 1903 that the ideal would be a thirty- or forty-bed hospital built on land adjoining the school on Huntington Avenue, and with provisions for future expansion. The possibility of obtaining control of the Emergency Hospital in Boston appeared in 1908, but nothing came of that.

The problem of having numerous part-time staff members

The most basic and persistent problem, and the one that was mentioned most frequently in connection with both medical and dental schools, was admission standards. The Board of Overseers, during its life-span of eight years (1899-1907), and the Boards of Visitors that it appointed during this period were constantly concerned. The president of the College expressed his views on the subject more than once. In their first formal report to the Trustees, the Overseers noted "with great satisfaction" the increase in the requirements for admission to the dental school and were inclined to approve the idea (soon put into effect) that the first year's work be made identical for both medical and dental students. A year later (in 1902) the Overseers expressed concern over medical school standards. "With the end in view of eliminating the least desirable material so that the entire work may be raised to a higher plane, we suggest that a substantial increase be made in the requirements for admission. The present definitions are far below the requirements for graduation from a good high school." The Committee on Education of the Trustee Executive Committee followed up this complaint and made a personal examination of the entrance papers in the medical school in the fall of 1902. They noted "with pleasure a tendency gradually to increase the requirements" and assured themselves that the catalogue statements were being "faithfully applied."

A small step was taken in 1902-3 to advance admission standards in the medical school when examinations were required in English, Latin, algebra, geometry, and physics of applicants who were graduated from high schools not on the "approved list." The fact that nearly 20 per cent of the applicants were rejected that year was produced to show that the medical faculty was "holding stiffly" to the admission requirements; in 1903-4, 37 per cent met a similar fate. The Boards of Visitors to the two schools were still not satisfied. It seemed to them something of an anomaly that a student could enter either the medical or the dental school on the strength of a diploma from a good high school or academy, while to take the medical preparatory course at a college, he was expected to be prepared to enter the A.B. or B.S. course. They were not yet ready to consider a college degree either wise or expedient as a requirement for either school, but they believed that "entrance requirements should be very high indeed to insure a reasonable chance of success for the applicant." The system of academic probation already in use in the Hill schools was adopted by the medical school in 1907 as one device for weeding out weak students. It was not until after the report was made on the medical school by the Carnegie Foundation in 1910 that any substantial change occurred in admission requirements. This did not mean a disregard of the problem before 1910, however. National trends in medical education could not be ignored.

President Hamilton had recognized in his annual report in 1908-9 the mounting efforts to improve standards for those entering the medical profession. The Johns Hopkins University and Harvard had gone so far as to require a college degree. A considerable number of schools had either adopted or given notice of intention to adopt the requirement of one or two years of college work as a prerequisite to admission to medical training. Standards varied, of course, from section to section within the United States. President Hamilton was sure that a New England preparatory education was equivalent to two years of college in most southern states. He believed that if any change were to be made, it ought to be in the direction of extending the medical course a year or more rather than requiring collegiate preparation. The lengthening of the time before a physician obtained his license to practice had been brought about already by the growing tendency to require a year of

It is no exaggeration to say that medical education in the United States was shaken to its foundations in 19l0. Two years before, the Carnegie Foundation for the Advancement of Teaching had instituted the most thorough and far-reaching investigation of medical schools in the United States that had ever been undertaken. The report, prepared for the Foundation by Abraham Flexner, a prominent educator, became one of the most controversial landmarks in educational history.[8]  The Flexner Report, as the Carnegie-sponsored investigation soon came to be called, was not the first survey of its kind in the field of medical education. The initiative had been taken by the Illinois State Board of Health in 1881. Up to then, only scattered statistics existed about medical schools, buried in the reports of the United States Commissioner of

This publicity, unwelcome as it was to many schools, performed a valuable service and no doubt strengthened the hand of a new and powerful agency created under the auspices of the American Medical Association after its reorganization and incorporation in 1901. The Council on Medical Education, which came into being in 1903 and held the first of its annual conferences in 1905, undertook to establish standards for medical education by setting, as a minimum, graduation from a four-year high school plus four years of medicine and recommending as desirable a five-year medical curriculum of which the first year would include physics, chemistry, and biology. The first inspection of medical schools by the Council, reported in 1906, was severe in its criticism of poorly equipped and inadequately staffed institutions; for example, of fifty-four schools in five states, less than ten were giving what the Council considered adequate training. For the next inspection a year later, the Council established a Class A, B, and C rating, each based on a ten-point factor on a ten-point scale. Schools achieving a Class A rating required seventy points; Class B ("doubtful" schools) ranged from fifty to seventy points; and Class C ("unacceptable" schools) were those assigned less than fifty points.

The results of the survey of 1907 were prompt and effective. Thirty-eight additional schools had decided by 1910 to require one year of preparatory work in college (including chemistry, physics, and biology), and several inferior schools surrendered their charters when licensing boards refused to examine their graduates. The next inspection paralleled the Flexner Report and was overshadowed by it. The coincidence of the two reports, one from outside the profession, gave rise to understandable controversy.

The story back of the Flexner Report represented in itself a

In order to make a determination of what institutions deserved Foundation favors, its Trustees undertook the self-appointed task of investigating and making public its findings. The justification for this ambitious and possibly audacious plan was Pritchett's conviction that all colleges and universities, whether public or private, were "in truth public service corporations," and because they were vested with a public interest, the public was entitled to be informed. Pritchett insisted that the Foundation "carefully refrained from attempting to become a standardizing agency" but he admitted that its influence was being used to make a differentiation

The investigations of medical schools were as comprehensive as it was possible to make them in less than two years. Personal visitation, interviews, college catalogues, information in the files of the American Medical Association and the Association of American Medical Colleges were all used as bases for evaluating the 150-odd schools surveyed. Data were then cross-checked by independent observers to assure accuracy and completeness. The conclusions to which the Foundation came boded ill for many a medical school. They called, in fact, for a complete reconstruction of medical education. Confusion bordering on chaos seemed to prevail in the field. There was no uniformity in standards, which were for the most part disgracefully low. A disturbingly high proportion of medical faculties that claimed some relationship to an academic institution represented "only a license from the college by which a proprietary medical school . . . was enabled to live under its name." As Pritchett viewed the results of the Foundation study, the situation which was uncovered seemed nothing short of scandalous.

The Tufts Medical School was visited in October 1909. Flexner found it "administratively an integral department of Tufts College, though actual scientific intercourse [was] not intimate." Enrollment was 384 and there was a teaching staff of 103, one-third of whom held professorial rank. Entrance requirements left much to be desired. Even though the school professed to accept at face value diplomas only from "approved" or "accredited" high schools (i.e., those on the list of the New England College Entrance Certificate Board), it allowed also an "equivalent." Under this rather ambiguous provision, in 1909-10 the school had accepted a total of 151 first-year students of whom only slightly more than half complied with the announced standard. Of the others, thirty were accepted from non-accredited schools on the strength of diplomas and certificates that, according to the catalogue statement, were not acceptable. The remaining thirty-eight were accepted under the heading of "equivalent" by taking entrance examinations that approximated about half of the subjects usually taken in high school.

The Flexner Report noted a close correlation between high drop-out rates and schools that allowed "equivalents." Tufts was cited as a glaring example. The entering class of 1908-9 was 141; of these, seventy-five were promoted (some with conditions) into the sophomore class. Of the remaining sixty-six, only fifteen departed before the final examinations, leaving fifty-one who were neither advanced nor dropped. It was painfully clear to Flexner that a high proportion of that particular class should never have been admitted in the first place. Even though Tufts was considered in the report to have one of the seven strongest medical schools in the United States that operated on the "high school or equivalent basis," the statistical evidence of academic mortality for the seven schools taken together was of great concern.[10]  To make matters worse, medical schools indulged in the pernicious habit of admitting each other's rejections or failures. Tufts, for example, admitted (as "specials") failures from Dartmouth, Queen's College (Kingston, Ontario), and the Medico-Chirurgical College of Philadelphia. Likewise, failures from Tufts appeared in the student body of the Baltimore Medical College. Tufts could take some small comfort from the fact that at least it was not guilty, as were so many of its fellow medical schools, of advancing students who had been refused promotion in other institutions with even lower standards.

The Carnegie survey found the laboratory facilities of the Tufts Medical School "entirely adequate to the teaching work," but the failure of the school to have its own hospital was noted with disapproval. There was one extenuating circumstance that allowed it to be classified among "the best of the schools without a

Possibly the most serious weakness of the Tufts Medical School, as both the College and the Flexner Report viewed the situation, was the lack of a bona fide endowment and the resulting dependence on tuition and fees to support the school. Medicine, said the author of the Carnegie Report, could not be and was not being properly taught on the basis solely or largely of receipts in the more than thirty university-affiliated medical schools or departments where this situation existed. Something had to be sacrified in the way of buildings, improvements, staff, or other requirements. Too many schools had to siphon off part of their income to pay off indebtedness. Tufts was used as an example of this unfortunate situation; the medical school, with an annual income of not quite $60,000, was paying off in yearly installments the debt incurred for the building it shared with the dental school.

The theme of the Flexner Report was simple but profound in its implications. It called for a complete overhauling of the whole field of medical education. Low standards, wasteful duplication of effort and facilities, undignified scrambling for students, and what appeared to be a callous disregard for the public welfare all had to be eliminated if medical schools were to meet in even a small way the demands of a society that was being weakened by unprofessional and sometimes downright unethical standards of education beyond the high school. The nation was being short-changed.

Several conclusions emerged from the nation-wide study of medical education. There was "an enormous over-production of uneducated and ill trained medical practitioners." This was due in the main to the "very large number" of commercially operated schools interested only (or primarily) in profits. As the expenses of operating medical schools mounted with the shift from didactic to laboratory-based teaching, the inadequacies of the weaker schools became alarmingly evident. Too many universities had annexed medical schools without either assuming responsibility for their standards or providing them with the resources they desperately needed, and had let the medical department become an imperium in imperio through neglect or weakness. The argument that catering to the poor boy justified a poor school was specious, fallacious, and insincere. Finally, a hospital connected with a medical school was as indispensable as a laboratory in chemistry or pathology.The long-range goal should be a much smaller number of medical schools, better equipped and conducted, and, as an end-product, fewer but better-trained physicians. Closer articulation than existed in most instances had to be provided between medical schools and universities to which they were attached or related in some degree. One trend approved in the Flexner Report was the articulation of the curricula of medical schools with the first two years of college - a tendency already evident in the North and and East (but not including Tufts).

According to the blueprint prepared by Flexner, of the some 150 medical schools in existence in 1909-10, about 120 should be "wiped off the map" by closing or merger.[11]  He called for thirty-one

If the proposals in the Flexner Report were taken seriously and were actually carried out, one immediate result would be to wipe out "a thoroughly wretched institution, like the College of Physicians and Surgeons of Boston." Whether even Boston should continue to support two regular schools (Harvard and Tufts) was "decidedly doubtful." The Tufts enrollment, even on the high school basis, was "much swollen." If strict enforcement of even that relatively low standard took place, it would greatly reduce attendance. The school had no resources but fees. Legitimate financial demands for the near future could not possibly be provided from this source alone. The "remarkable prosperity" the school had shown had "depended to no slight extent on the inducement held out by low entrance standards." Its "only hope of escape" lay through endowment so that its laboratories could be developed independently of tuition income and a hospital could be secured. This was an expensive step that would take years to achieve and would still not solve the dilemma of overproduction. There was no alternative, in Flexner's view, but to close out the Tufts Medical School as well as all similar schools in Maine, Vermont, and New Hampshire. There was no good reason, said Flexner, why Dartmouth, Bowdoin, and the University of Vermont should be concerned with medicine at all. He did suggest that the Tufts Medical School be merged with Harvard rather than be as summarily disposed of as the College of Physicians and Surgeons. This might have seemed a less drastic alternative, and at least recognized that there was something worth salvaging, but in any case the Tufts school would have disappeared as an institutional unit.

No one school had been singled out as the target of the monumental Flexner Report. All medical training institutions in the United States were subjected to the same scrutiny and not one escaped criticism of some sort. But no matter how devastating the report might have been, and no matter how many institutions sent out howls of anguish, the intent of the Flexner study was worthwhile. It might be said in historical perspective that the Flexner Report represented what the author himself designated as the third stage in the development of American medical education. As he expressed it, the apprenticeship ("preceptorship") stage had been passed, the didactic method was on its way out, and medical education should be ready for the third step - the recognition of medical training as a "scientific discipline" that took the principle of the first stage, refined it, and added to it half a century of accumulated medical knowledge. The Flexner Report was a conscious attempt to usher in a new era.

Some of the repercussions and reverberations of the Flexner Report were heard and felt at the Tufts Medical School almost immediately; others took longer to show their effects. The implications of the report could not be swept under the rug either at the Boston-based school or by the medical profession at large. Nationally, the impact of the report was explosive. The Association of American Medical Colleges bestirred itself; there was a rush for university affiliation; the number of medical schools declined precipitately.[12]  Controversial or not, the Flexner Report had launched a revolution in medical education.

The reactions of Tufts and its medical school staff were varied. Most of the sensitive points in the Flexner Report had already been discussed or had provoked some amount of concern although agreement was not always to be found or to be expected. Probably very few individuals felt as strongly as Edwin Ginn, who served on the Board of Overseers from 1899 to 1907 and was later elected an alumni Trustee. He had been "very doubtful" in 1900 about the advisability of "annexing so many schools when the funds are so limited" and in 1904 had declined to serve on the Board of Visitors

One prompt reply to the Flexner Report was the resignation of eight members of the medical school staff. Some of the resignations were merely a coincidence so far as timing was concerned, but at least three were not. The disaffected faculty who did depart were led by Dr. Horace D. Arnold, Professor of Clinical Medicine, who had been associated with the school since 1897. He proposed that the entire staff of the medical school be dismissed and that he be made dean with a free hand to reconstruct the whole school. The existing Tufts buildings were to be left for the use of the dental school and students in the first year of the medical school curriculum. Advanced work was to be done at the Harvard school under Harvard instructors. The new arrangement would be known as the Harvard-Tufts Medical School, and Harvard degrees would be awarded to those who could meet Harvard requirements; those who could not would receive Tufts degrees. President Hamilton's reaction to these suggestions was a masterpiece of restraint and understatement; Dr. Arnold's whole proposal was "inadmissible." The Department of Clinical Medicine was to be reorganized (without Dr. Arnold), and clinical facilities could still be maintained at the Boston City Hospital, even without his presence.

The sentiments of Ginn and Arnold were strictly minority expressions. It was up to Dean Williams to voice the views of the majority of the medical school staff and to undertake the none too pleasant task of making some sort of reply to allegations and the factual evidence embodied in the Flexner Report. He devoted parts of several annual reports to the subject. His first reaction was defensive, as it should well have been in view of the fact that the very existence of his school was conceivably at stake. Some of his arguments were well taken while others had an unconvincing ring about them. At least the Flexner Report had prompted some stock-taking. After commenting that the report had been compiled "by gentlemen not physicians, and hitherto professing no knowledge of medical training," he turned immediately to a piece of good news. Simultaneously with the publication of the Flexner Report there appeared a report by the Council on Medical Education of the

The report of the Carnegie Foundation, in Dean Williams' opinion, was "ill-considered and based upon a superficial knowledge of the facts." It would, in his belief, work to the detriment of medical education instead of its betterment. He admitted that the Foundation exerted a great influence, and even some degree of control, particularly over Class A schools. The stiffening of requirements to "an arbitrary standard" would inevitably result in a decline of enrollment in the better schools and an increase in the enrollments of the weaker and inferior schools, to which students would flock who had been refused by the better schools.

Williams countered the allegation that the medical school existed on fees alone by calling attention to the affiliation of the dental and medical schools. This argument was perfectly sound but it proved very little inasmuch as the dental school had no endowment either. He pointed to the fact that both schools were well equipped and well financed. There was a sinking fund of $12,000 and $5,000 in annual income for research (the Johnson Fund). By his reckoning, the income of over $59,000 taken together with the other two items equaled the interest on an endowment of nearly $200,000. The dental school income the same year (1909-10) was over $50,000; its "endowment" (by adding in buildings and equipment) was $48,000; and its sinking fund was $5,000. Large savings were also being effected by combining several branches of medicine common to both schools such as anatomy, physiology, and chemistry, and by using the same laboratories, lecture rooms, and administrative services. This by no means meant that an endowment was

No matter how upsetting the Flexner Report might have been, there was no sign that the medical school was going to fold up its tents. The best it could do was to continue on its way, but to recognize the weaknesses made so painfully evident in the Carnegie study and to try where possible to do something about them. Even if the Flexner recommendations had not been made, the Tufts Medical School would have had to do something about admissions out of self-defense. Bulging enrollments after 1910 made an upward revision of requirements mandatory. Up through 1909-10, a diploma from an accredited high school served as a ticket of admission. Beginning the next year, a diploma from a school not listed by the New England College Entrance Certificate Board was supposedly unacceptable. Examinations were necessary for students from such schools, and in any case students were required to be proficient in physics, Latin, and chemistry.[14]  A sharp reduction in enrollment was correctly forecast, although it was a temporary phenomenon. The medical school undoubtedly lost some promising potential students, as some high schools were not certified because they had not sent sufficient numbers of graduates to New England colleges to be entitled to certification by the Board. Graduates of such schools preferred entering medical schools where their diplomas were acceptable to taking Tufts entrance examinations.

Dean Harold Williams noted with elation in his annual report for 1911-12 the affiliation of a hospital with Tufts. It had been something long sought, and one of the needs prominently mentioned in the Flexner Report. The acquisition of the facilities of Grace Hospital on Kingston Street in Boston gave the medical school direct medical and surgical control over a hospital for the

The possibility of obtaining the use of Grace Hospital had been discussed for over a year by the Trustees after the hospital had been placed in receivership. They had been contacted by one of the receivers, who knew that the medical school was in need of its own hospital. The first reaction of the Trustees had been negative, for they had sufficient financial problems to solve without adding another. However, after extended conferences with the receivers, the Administrative Committee of the medical school, and the owners of the property occupied by the hospital, the Trustees reluctantly negotiated a two-year lease (April 1, 1912, to June 1, 1914). In presenting the report on which favorable action was taken by the Trustees, their special committee put their lack of enthusiasm on record. They had been "governed exclusively by what has been represented to us as the 'needs' of the medical school for facilities of this kind." Furthermore, those responsible for the conduct of the medical school and the dental school (which was also to use its clinical facilities) had to have impressed on them the fact that failure to bring and keep their school "within their financial responsibilities" would "make it necessary for the absolute and positive discontinuance of all efforts to maintain directly or indirectly any hospital accommodations." The skepticism of the Trustees as to the workability of the Grace Hospital arrangements was borne out, for the lease was canceled before the two-year period was up. Clinical needs were found to be sufficient through existing channels, and Mt. Sinai Hospital had been added in 1912 to the resources available to Tufts medical students.

The Tufts Medical School continued to pass muster at the hands of various accrediting agencies. It became a member of the

[7] Dr. Hildreth resigned as dean in 1898 and was replaced by Dr. Harold Williams; however, Hildreth retained his post in clinical medicine.

[8] Abraham Flexner, Medical Education in the United States and Canada (New York: Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4, 1910).

[9] The history of the stormy early years of the Foundation is to be found in Theron F. Schlabach, Pensions for Professors (Madison: State Historical Society of Wisconsin, 1963).

[10] Of 2,280 students in 1908-9 in the seven (Jefferson Medical, New York University, University of Maryland, the Medico-Chirurgical College of Philadelphia, Yale, the University of Pennsylvania, and Tufts), 11 per cent dropped out before taking examinations, 38 per cent either failed or were conditioned, and only 51 per cent passed without conditions of some kind.

[11] This was more than a figure of speech. Flexner included in his report two outline maps of the United States showing the actual and proposed distribution of schools after reduction had taken place.

[12] Medical schools had been reduced to ninety-five by 1915, of which sixty-five held a Class A rating. Five years later the total number was down to eighty-five, and in 1927 there were eighty, with seventy-one Class A schools (of which nine taught only the first two years of medicine).

[13] This had followed on the heels of a similar report made in 1908 in which the Tufts school had received a Class I rating - among 64 such schools out of 149 investigated.

[14] The medical school faculty struggled for some time over the chemistry requirement. In the spring of 1910 it was voted that general chemistry be a requirement for admission beginning in 1911-12. But when the time came to put the requirement into effect, chemistry was put in the Elective rather than the Required group. The faculty reversed itself in the middle of the academic year 1911-12 and again voted to require chemistry for admission. Biology was similarly required after January 1, 1913.