Several other events of importance occurred in the history of the medical and dental schools in 1913 and the years immediately following. After fifteen years' service as the dean of both schools, Dr. Williams retired. He was succeeded by Dr. Charles F. Painter, who had been on the medical school staff since 1897 and was to continue as the dean of both schools until 1917. The medical school had grown sufficiently in numbers and complexity by 1913 to require a reorganization of its internal administration. The staff had been so enlarged, and so many courses and subjects had been added as medicine itself extended its boundaries, that the efficiency of the school's work was being impaired. The result was the division of the medical school into six departments: Medicine, Surgery, Obstetrics and Gynecology, Chemistry, Physiology and Therapeutics, Anatomy and Pathology, and Specialties. Each department had its own organization and provision for frequent consultations of its faculty and staff. Departmental needs were expressed through a Committee on Instruction, on which each was represented. The creation of this body relieved the Administrative Committee of much of the burden of settling purely educational matters and allowed it to concentrate on the business affairs of the school and the

Of even greater importance in the field of medical education was the decision of the American Medical Association to refuse a Class A rating after 1913 to any school that did not require one year of college work in biology, chemistry, physics, and a modern foreign language. The rapidity of progress in medicine and surgery made the requirement inevitable. Neither the Tufts Medical School nor a majority of medical educators at large were yet prepared to require a college degree as a prerequisite to professional training, although a scattering of institutions had already taken this step before 1913. Whether a full college course was ever to be required or not, it seemed that the time had come for medical schools to turn over training in medical fundamentals to the colleges.

The requirement of a year of college preparatory work made mandatory the establishment somewhere in Tufts of a formal pre-medical curriculum. There had been concern already expressed about the long and expensive pre-professional and professional training period demanded of potential physicians. The Flexner Report of 1910, which was still very fresh in mind, also had had considerable to say about the proper basis for a medical education. Flexner's conclusions had been inescapable. Such fundamentals as biology, chemistry, and physics could not and should not be taught in the medical school proper. Some sort of preliminary technical education had to be provided, and the college was a more appropriate place for it than the high school. Because of the need for laboratory work, two years rather than one was desirable. This might have been too much to expect at the outset, but at least one year was required by over 80 per cent of medical schools by the time of the First World War; Tufts became part of this statistic.

One year of college work was added to the existing requirements for admission to the Tufts Medical School, beginning with

In the fall of 1906 the medical school had been asked by the Council on Medical Education for its reaction to a proposal to require one year of college after 1910. The committee to which the matter had been referred waited over a year to return a reply, which was negative. The Association of American Medical Colleges had sounded out the medical school on the same question in 1909 and received the same reply, although the medical faculty commented that they would look favorably on a five-year course in the medical school itself. During the previous year the faculty had discussed (but not acted on) a proposal to request the Tufts Trustees to establish a program whereby a student who had successfully pursued a two-year medical preparatory course at Tufts could receive a B.S. degree at the conclusion of two additional years at the medical school and receive the M.D. upon completion of the four-year medical curriculum.

The officers of the Tufts Medical School and the College administration were kept on tenterhooks for most of 1912 by both the Association of American Medical Colleges and the American Medical Association. The former organization had put the Tufts school on its "doubtful" list because it admitted students in direct violation of the requirements of all approved medical schools, as judged by the American Medical Association; because it had no hospital; and because its clinical facilities were inadequate for its size. Throughout all this uncertainty, the medical school managed to hold on to its Class A rating, however precariously.

The question of requiring a preparatory college year received its first full airing in the medical school early in 1913; the resulting faculty report embodied all the arguments that could possibly be marshaled against the proposal. The reasoning went substantially as follows. Although the faculty fully realized the "magnificent work" done by the Council on Medical Education in eliminating poor schools, in raising the standard of entrance requirements, and

The medical faculty reluctantly agreed to abide by the decision to require a year of college and so voted in the spring of 1913. In order to dispel any doubt as to their intention, they voted further that the pre-medical training "shall not be taken in a high school." But the debate was far from over. Dean Williams, for one, was unsympathetic to the change. As he made his last annual report as dean in the fall of 1913, he left the parting warning that a grievous mistake was being made in medical education. He felt that the establishment of higher entrance requirements was not the vital point. It was the results of medical training that were important, not the more or less arbitrary admission requirements, and the Tufts Medical School had an excellent record as a first-class institution. He believed that a high school education was sufficient, that the policy of weeding out weak students at the end of the freshman year was working well, and that many promising candidates for the medical profession would be excluded by summarily raising admission requirements at the demand of an outside agency.

Dean Williams' successor faced a faculty close to rebellion in 1914. The Committee on Instruction called for a full discussion of entrance requirements and suggested the alternative of rescinding or suspending the action of 1913 to require a pre-medical year, or

Actually, the ingredients of a pre-medical program were already available in the Hill departments of Tufts. The dean of the medical school had pointed out in his annual report for 1894-95 that training in the elementary courses taught in the medical school could be obtained under the supervision of the Department of Biology on the Medford campus. A four-year sequence of courses appropriate for prospective medical school candidates was first listed in the catalogue in 1895-96. While the Flexner Report was in the process of being prepared for publication in 1910, a one-year undergraduate science course was announced in the school of liberal arts. This was intended as an aid for those with insufficient background in subjects such as biology, chemistry, physics, English, or modern foreign languages, and was to supplement and not replace high school preparation. The medical school itself received permission from the Trustees in 19 1 to open a summer school in chemistry "for candidates for admission to the medical school."

The next step in the evolution of a formal pre-medical program on the Hill was the adoption of a four-year sequence effective

Neither Acting President Hooper (who succeeded Hamilton after the latter resigned in 1912) nor Dean Painter took as pessimistic a view as had Dean Williams of the effect of the increased medical admission requirements, although Painter had some reservations. The first-year enrollment in the medical school dropped sharply, as was to be expected, but Hooper sensed greater enthusiasm in the medical faculty, general approval within the medical profession, and more cordial relations between the school and hospitals providing clinical opportunities. As a matter of fact, in 1913 and 1914 the medical school obtained enlarged clinical facilities almost everywhere that connections were being maintained. The most important new clinical asset was the placing in charge of the medical school of an entire fifty-bed ward at the Boston City Hospital. This provided most of the advantages earlier thought to exist by using the Grace Hospital, but with none of the financial responsibilities and perplexities that had beset the Trustees. Increased access to the Robert Brigham Hospital was also obtained, as well as at the newly opened St. Elizabeth Hospital.

One of the firmest statistical grounds for optimism was a rapid rise in enrollment in the so-called "pre-medical year." Seventeen students had been enrolled in the last year of the optional one-year program in Medford in 1913-14, and 102 started out in the new required course. But the brightness of the academic atmosphere was clouded almost immediately when the medical school again ran afoul of the American Medical Association. Unlike the pre-1914 course, the new pre-medical program during 1914-15 was conducted by and at the medical school, where tuition was set at $100. At the close of the academic year the Association directed that the

Throughout the period of rapid change and readjustment in medical education, Dean Painter maintained an attitude of cautious conservatism. While subscribing to all that had been said in favor of properly educated physicians, he thought there was still "reasonable ground for debate" as to whether the new methods were in all respects the best. The worst thing that could happen was to force changes too rapidly. He blamed inadequate preparation by secondary schools for the necesssity of installing a premedical curriculum, and state Boards of Examiners for exerting undue pressure to require college preparatory work. He believed that medical schools "should not be stampeded into calling for a two-year college preparation" for entrance to the Tufts Medical School until reforms were brought about in secondary education.

Dean Painter could scarcely have been more correct when in 1914 he included in his annual report the statement that "the last word has not yet been said" as to what was a proper standard of entrance requirement for a medical school or a proper medical school curriculum. After a year of discussion the American Medical Association adopted in 1917 a report of a special committee representing the Association, the Association of American Medical Colleges, and the Association of American Universities to require two years of college. A second year of college would provide opportunity for additional work in mathematics, foreign languages (French

This new requirement threw the medical school into consternation. It had not yet even had the opportunity to complete the readjustments necessitated by the requirement of one year of preparatory education. It appeared that the school was being discriminated against or at least put at a distinct disadvantage competitively for Massachusetts was not among the thirty-seven states that had required even one year of college when the preliminary report had been made in 1917. Dean Painter accepted the new directive with as much resignation as he could muster and made the pointed remark that he assumed the public from which the medical profession was being recruited were aware of the added time and expense that the new program would entail. The Tufts Trustees made the new requirement for admission to the medical school effective September 1917. The customary loophole was left whereby a high school graduate could demonstrate the educational equivalent by special examination, but students were advised to pursue the full college program if possible. The new two-year pre-medical curriculum required sixty-nine credits, somewhat above the minimum of sixty requested by the American Medical Association. The responsibility for working out the program was placed by the Trustees in the hands of the president, the dean, and the faculty of the school of liberal arts.

Increased requirements or no, the enrollment in both the premedical program and the medical school swelled so rapidly that the staff and the facilities were literally swamped. Even the dislocations of the First World War seemed to have only a small net effect on the growth of both. Overcrowding, overused equipment, and building suffering constant wear and tear became chronic. Even an increase of $25 in tuition in the medical school seemed to make no difference. The medical school enrollment in 1920-21 was 452 and in 1921-22 was 470. The situation was neatly summarized by John A. Cousens, who had assumed the presidency of the College in 1919-20. "The enrollment is too large to be compatible with our ideals of medical education, but is fortunate for financial reasons."

One of the reasons for the strain on resources was the introduction of a one-year pre-dental program in January 1921 in compliance with the standards set by accrediting agencies in the dental profession, and in anticipation of a required rather than an optional four-year curriculum in the dental school which was to have gone into effect in 1921-22 but actually became operative in the following year. The pre-dental course was identical with the first year of the pre-medical school, consisting of biology, chemistry, physics, English, a modern foreign language, and mathematics. Like the pre-medical program, the pre-dental course was offered at the medical-dental headquarters in Boston but was under the supervision of the dean of the school of liberal arts. Even though the pre-dental school was opened in the middle of the academic year, there were already nineteen candidates on the waiting list the previous October, and the dental school enrollment correspondingly shot up to 525 in the fall of 1920-21 before the requirement of five years beyond high school was to have gone into effect.

President Cousens told the Trustees in the fall of 1921 that limits on enrollment had to be set until an expansion in physical plant could be provided. The maxima were to be 450 for the medical school, 500 for the dental school, and 400 for the combined pre-medical and pre-dental schools. The enrollment in the medical school the next year was twenty over the ceiling set the previous year and was justified on the ground that the dental school enrollment dropped sharply because of the requirement of one year of college. The "saturation point" in pre-medical and pre-dental enrollment referred to by the president was also exceeded immediately. To make matters more complicated, the requirement of a

The crisis brought on by the transition to a four-year dental course did not require such a step. Enrollment slowly climbed back to almost normal figures. Meanwhile, the swollen enrollment in the pre-medical and pre-dental courses and in the medical school became a matter of urgency. It appeared, in fact, as though matters had gotten out of hand. The fact that student fees were of "the utmost importance" meant an unfortunate tendency to accept too many applicants. President Cousens, unwittingly or not, put his finger on the basic problem in his annual report for 1924-25. "Emboldened by success in other years," the medical school advanced tuition in 1925 from $225 to $300.[15]  The advance, which applied to upperclassmen as well as to entering students, "occasioned no unfavorable comment whatever and has increased the revenue of the school to such an extent that there is a substantial margin of safety as indicated by the budget." In spite of the increase, the number of applicants rose to over 600. This did not necessarily mean that admission standards were disregarded or that the quality of the product of the two schools became an embarrassment to the College. There was such a demand for the products of both medical and dental schools that the mere force of numbers of applicants resulted in a screening process that helped eliminate the weaker candidates. Nevertheless, there was dissatisfaction and concern in many quarters. Because of the very existence of the premedical and pre-dental curricula, well over half of first-year medical and dental classes came from the pre-professional programs. In 1922, only 25 per cent of the whole medical school student body held college degrees - far below the national average.

Dr. Stephen Rushmore, who had been associated with the

The College was able to retain Dean Rushmore's services as long as it did because President Cousens attempted to obtain financial support from the General Education Board, which administered funds allocated by the Rockefeller Foundation for medical education. Some token assistance was obtained on a matching basis, but the long-range proposals made by the Board were completely outside the capabilities of the College. Dr. Flexner, who served as the spokesman for the medical section of the Board during much of the 1920's, conferred with the president and the dean and made suggestions that Cousens described as "Utopian dreams." Flexner told them that he would recommend $5,000,000 in assistance if

The Board of Visitors to the medical school in 1926 also dealt at length with the problem of location. Existing facilities were notoriously outgrown and inadequate, and the school was not conveniently close to large hospitals that had on their staffs members of the Tufts teaching force. The idea of moving the medical school to the Hill and erecting a modern hospital there was a "magnificent. dream" that would require $10,000,000 to bring into actuality. "We have to deal with the facts as they are and not as we would like to have them." There seemed only one practical course: dispose of the holdings on Huntington Avenue and move the medical school as close as possible to a large hospital. The Boston City Hospital seemed to be the best choice, regardless of whether the dental school was also moved. Even this solution would have involved extraordinary expenses and readjustments; it was also opposed by Cousens, partly on the ground that such a move would mean the abandonment of "all hope that our school shall ever be of absolute first grade."

Dean Frank G. Wren, of the school of liberal arts, who was responsible for the administration of the pre-medical and pre-dental schools, suggested in 1923 that a partial solution to the many problems facing the two professional schools in Boston would be the raising of entrance requirements for the pre-medical program to make them comparable to those of the rest of the College. All that was required was a transcript and certification of graduation from an approved high school; there was no reference to the quality of the work. He was not, however, yet willing to abolish the program or to add or change course requirements that would make the

The medical school Admissions Committee recommended in 1926 that the proposed change be effected. Dean Wren suggested that the requirements go into effect in the fall of 1927, but the medical faculty postponed the effective date until January 1, 1929. This delay came on the heels of an inspection of the medical school by the Council on Medical Education in 1926. The points made in their report were hard to refute: that a two-year pre-medical education failed to equip the student as well as would attendance in a regular college or university, that more and more students were applying to medical schools who already had earned the first degree, and that Tufts College could do well to abandon the special program.

It was at this juncture that Dean Rushmore decided to do battle no longer. He submitted his resignation in 1927. He did not look favorably on the pre-medical curriculum as organized at Tufts and felt that the College had failed to cooperate with both the spirit and the letter of the various professional agencies to which the medical school was accountable. Consequently, the Class A rating of the school had seemed all too often to be hanging by a thread. Endowment and a hospital were still lacking, as every outside accrediting agency had tiresomely reminded him. Every effort to make a change had been an uphill struggle and somehow had seemed to him to stop just short of the goal. He was even more

The history of the one-year pre-dental program since its inception in 1921 had followed a course almost identical to that of the pre-medical school of which it was a part, and admission requirements were the same. The decision was made in the dental school in 1926 to follow the medical school's requirement of two years of college work for admission, effective in 1927. Dean Wren was reluctant to have the requirement go into operation immediately because of the effect it would have on dental school enrollment, and President Cousens considered the new requirement unnecessary.[16]  A two-year pre-dental program was arranged, nonetheless, with courses in English and American literature, psychology, elementary economics, and American history and civics intermixed with advanced work in biology and chemistry in the second year.

The problem of what to do about the pre-medical and pre-dental programs was solved by the Trustees in 1927. They seemed to have no other course. They voted to close the two pre-professional programs at the end of the academic year 1928-29. The last entering class (September 1927) was to attend the Huntington Avenue location. Thereafter, all pre-medical and pre-dental work was to be conducted by the liberal arts faculty in Medford, and a course within the school of liberal arts intended for medical and dental students and leading to the Bachelor's degree, if desired, was to be established within the existing framework of the College. The raising of medical and dental school admission standards made the continuance of the separate pre-medical and pre-dental school a needless duplication and a waste of precious resources.

There is little doubt that many of the difficulties surrounding the whole pre-medical and pre-dental experience, and many of the problems of the medical and dental schools, would have been alleviated or would never have risen at all if it had not been for the financial bind in which the College perpetually found itself, and

[15] The net increase was actually only $50, for laboratory fees were abolished simultaneously.

[16] The enrollment in the pre-dental school was 123 in 1925-26.