Dr. Robert C. Shamberger - A Brief History of Boston Children’s Hospital

So for those of you who were there, you've heard part of this presentation already. So as we have over 150 years of history to go and I promise less than 150 slides, I'd like to go ahead with the presentation this morning. So in the 19th century, there were very few hospitals in the United States. Despite the fact that nearly half of the deaths were due to children, there were no pediatric hospitals. Philanthropist and physicians in Boston were determined to do better. In 1847, the initial effort to establish a hospital for children in Boston occurred with the support of this gentleman, Amos Lawrence. He was a wealthy textile merchant with multiple mills along the Merrimack River. These efforts resulted in the creation of the Boston Children's Infirmary. The patients who were seen there were very sick, very poor, and could not afford the care of the home in their home where most patients were treated at the time, particularly children. Mr. Lawrence's son, Dr. William Ardorance, was essentially involved in the management of the infirmary. He remained open only for 18 months during which time 192 patients were admitted before it was closed for financial reasons. The reason for its failure was said to be that deep rooted and commendable feeling, which prompts the mother to cling to her sick and suffering child rather than entrust the child to those whose motives she never learned to understand. But given the limited tools that medical practitioners had at their disposal at this time, compassion, and faith, hygiene, and nutrition, that may not have been an entirely unwarranted response. It said that the early collapse of this children's hospital effort led the subsequent board of trustees of this institution to be very conservative where their fiscal approaches to the world. Further efforts to establish a children's hospital did not occur until after the Civil War in 1869, that day which we were celebrating for our 150th anniversary. Francis Brown and HMS trained surgeon who shown here and three other colleagues, all of whom served as surgeons during the Civil War, established the predecessor of the children's hospital at Rutland Street in the South End, which is just behind the old Colonate Hotel. A year later in 1870, the hospital moved to a second 20-bed facility located at the corner of Washington Street in Rutland, which is shown here. I think that you not be lost on any of us that the foundation of this hospital was created by four surgeons. This effort was better supported than was the children's infirmary by philanthropy and an organization, the Ladies Aid Association, which provided the essential supplies, and there was no charge for the care of the children, which was good because most of them were very poor. But please, such as these, for financial support for the new institution, more frequent in the press, where it says the managers of children's hospital find it necessary to make an immediate and earnest appeal in behalf of the most interesting institution. We obviously have to continue those pleas to this day for financial support. At this time, children of wealthy families continued to be cared for in their homes. Also critical to the success of the hospital was hiring an efficient manager, Adeline Beard Tyler. I don't think any of us would argue with this lady in her countenance. She served as the first superintendent of nurses for three years. She was in succeeded by sister Teresa and the Anglican Order of the Sisters of St. Margaret, who served the hospital for 45 years after they arrived from England and established a content in the Weasberg Square on Beacon Hill and a plaque to honor that organization is present on the first floor of the Honeywell Building. The reappearance of a children's hospital on the scene was not immediately embraced by all. In fact, Dr. Benjamin Shaw, who was a resident physician at the Massachusetts General Hospital, which is shown here. This is the MGH and this is the Harvard Medical School at that time. Wrote a letter of dissent in the Boston Daily Advertiser stating that in the last three years, 14% of the admissions to the MGH were children and that a similar number were treated at Boston City Hospital. He declared that our existing institutions, public and private, provide adequately for the hospital treatment of children. So it's clear that medical conflicts among the institutions in Boston date back a long time. Here's shown a stylized depiction of the reception room at the Rutland Street site for children's hospital, which was published in Leslie's Illustrated newspaper. At the left, you can see the indispensable nun who upsupport the organization at that time. Somehow I find the tranquility of this scene a little difficult to accept unless the kids were different than they are now, which I doubt. In 1882, children had outgrown its 20-bed facility and the trustees had a successful capital campaign and obviously children's is just completed one. This one raised $95,000. He not's supposed to what we do now. Which allowed the construction of a new 60-bed facility which is shown here on Huntington Avenue. It was just down the street from where symphony hall would be built several years later. Dr. Brown had studied hospital design in England and Europe immediately after the Civil War and felt that fresh air and light were essential to the treatment of childhood illnesses. So this facility is shown here at lots of windows and high ceilings. Many of the admissions at that time were for orthopedic fractures, tuberculosis of the spine, and other infectious problems. You can see that the vast majority of the patients were actually treated for tuberculosis. Philhelm Rentgen discovered X-rays in 1895 and in 1899, radiographs were first obtained at the children's hospital. Ironically, the first escheeographer, as he was called, was Ernest Codman, who was appointed to that position using equipment similar to that shown here. Certainly nothing like we see on our second floor. He would later become recognized as a surgeon who advanced the efforts on quality assessment at the mass general hospital. This development of radiology significantly contributed to the care of patients primarily admitted for orthopedic issues. Here we can see a slide of an early operating room, the orthopedist with their inevitable hammer. Note the absence of the mask in the operating room even at this time around 1900. After the demonstration of anesthesia in 1846 at the MGH, the inhalation of ether could make a surgery pain free. Anesthesia at that time was primarily administered in the OR by a nurse, as shown here with her cap, a medical student or a surgical resident. This later photo of the Huntington site shows the verandas which were built again to increase the air exposure for kids. Again, there wasn't much else the physicians had to offer kids at that time. I can only imagine what the joint commission would worry about the fall risk. The new hospitals started a program for education for medical students, many from HMS. In current with the move to Huntington Avenue in 1882, house officers were first appointed as interns and externs. By 1914 house officers are shown here were entraining for six months in a bowl of time. Somehow these gentlemen look a little different from the interns and residents we have now. The hospital only admitted children older than two years of age. At that point it was considered that babies were unsuitable as hospital patients, even if not separated from their mothers due to their susceptibility and defenselessness against the so-called fevers that plague children at the time, which made hospitals surround in extremely risky for them. A similar policy was extended at the Great Ormond Street, Hospital in London and the Children's Hospital of Philadelphia. Under the West End Nursery, which is shown here, was established in 1981 on Blossom Street right adjacent to the MCH. It was created a year before children's hospital would move to the location on Huntington Avenue. It later became known as the West End Nursery and Infants Hospital. Some here is the Infants Ward at the West End Nursery. When children's moved to Longwood Avenue, the Infants Hospital moved to building on what is known as Shadwick Street, which is shown here and many of us recognize this is what we call the wall back building, which was recently taken down for the construction of their new hailed building. Of note, Dr. Thomas Raj, who's shown here, became the director of the Infants Hospital, as well as physician and chief of Children's Hospital. He was the first chair of Pediatrics at HMS, and one of the longest standing chairs, funded chairs as that children's name, or as that Harvard in his name. This photograph shows an early milk laboratory he established at the Huntington Avenue Hospital. He felt that milk from infected cows was a major source of disease, especially among poor children. He was the first of a long line of physicians and surgeons at Children's, who would identify a clinical problem and subsequently create a research program to find a children. In 1894, the Boston Floating Hospital was established to provide a quote, healthy environment in which infants with diarrhea could recover from their illness. It was literally a large boat, as shown here on which children were taking during the hot summer months from the stifling heat of the city to the cruel Boston Harbor. At that time, there wasn't much the medicine had to offer these infants other than fresh air and light. 1927, a permanent structure was built on Terraforma for this institution, which is now associated with Tufts Mental Medical Center. Now Herbert Burrell, who's shown here served as chief of surgery for 20 years. He left an indelible mark on children's hospital when in 1906 he controlled the trustees into moving the hospital from the Huntington Avenue site to our present location on Longwood Avenue to be next door to Harvard Medical School. HMS had moved along with Avenue in 1906 from its prior location adjacent to the MTH. It was constructed with a $5 million grant from JP Morgan. Eight years later, children's hospital moved to its current site on a 3-acre partial of land, which was a former farm purchased for $120,000. Now, this move was widely opposed by the medical staff because it was seen as moving children's hospital into the country. In this image shows the rural setting. The real setting was at that time, here's children's hospital, it's Harvard Medical School, the Peter van Bergham hospital, in this large farm area in front. Remember this was still 15 years before Fleming's discovery of penicillin, which was not available while until 1940. The new hospital had initially 145 beds and drew a broader spectrum of patients including now those with polio, rheumatic fever, cleflet, churnias, and recurrent tonsillitis. Initially the east winning of the hospital, so this part, housed 70 nurses and had five rooms in which the sisters of St. Margaret could stay, which provided a critical ingredient for care of children at that time, which was lots of nurses. Is it note that when parents brought their children to be cared for at the hospital, it was standard practice that they were allowed to visit their children for one hour on Sundays. I don't know if that was an encouragement or discouragement for the parents, but one hour. It wasn't until February of 1968 that the staff executive committee discussed changing the visiting hours to 12 noon to 8 pm daily. Now the widespread pasteurization of milk did not start until the 1920s, and was one of the really major breakthroughs in public health. Between 1919, when only a third of the milk and Massachusetts was pasteurized in 1939, when almost all of it was, the number of outbreaks of milkborne disease fell by 90 percent clearly, testimony to the effects of public health. Here you can see the slide that we all see on our interview dates with the fellows as a cows in front of children's hospital, and these were maintained to provide safe, to burculant, free milk for our patients. Now the infant's hospital moved to Pavilion on the children's campus, which is shown here following the sale of its home on Shadok Street in 1923 to Harvard University. It contained several awards here, and it was obvious that children's hospital, at that point, had the same problem we have now, where our seams were bursting, so rather than building a large, new building, a multiple small buildings to overflow of children. This building also added the first neonatal unit to the hospital. Although children's and the infant's hospital were implicitly, closely allied and shared faculty, their official merger did not occur until 1956. And this shows the infant board in one of those units. Now, in 1910, William E. Lad joined the hospital as a surgeon. He was from a well-to-do Boston family, who was educated at Harvard College and Medical School, graduating in 1906. After graduation, Lad served as a house officer and then continued his training as an assistant to several of the staff surgeons at the Boston City Hospital. He didn't enter practice and spent a small amount of his time, cheering for the charity patients at children's hospital and Boston City Hospitalists and assistant volunteers surgery. He can share for his pain patients at smaller hospitals and in their homes. Now, surgery in the early years that children was quite different from what we enjoy today. Dr. Landman, who was one of the staff surgeons at the time, stated that, quote, a procedure lasting over an hour. That's hardly the anesthesia set up time. Sorry, guys. Was entering a very dangerous phase, prolonged operations on the GI tract carried a heavy mortality because of lack of knowledge of fluid balance and open-door economy was impossible. So we've obviously come miles with our anesthesia college today. As many of you are aware, particularly around the holiday season, a massive explosion occurred in Halifact Harbor on December 6, 1917. The French freighter, the SS Montblanc, carried load of TNT in its hole in highly volatile aviation fluid was strapped on its deck. It collided with the Norwegian freighter, the SS Imel, near the Tenement Laden north end of the city. Initially, the aviation fluid ignited on the surface of the water during children and adults to the windows, followed by a massive explosion from the TNT in the hole. The conflagration destroyed a large two-square mile section of the city. Hundreds died instantly, 4% of the population. And many, many more were blinded and had terrible injuries. And Boston, a group of physicians was mobilized and a train load of supplies was dispatched to Halifax. The leader of the 40-member Red Cross delegation was the young surgeon, William E. Ladd. Dr. Ladd was said to be particularly touched by those surviving children who were blinded and who had severe facial injuries from having been at the windows when the giant explosion shattered the glass in front of them. Now, it's a deeply entrenched lore in pediatric surgery, and it was often reported by his training Robert E. Gross that Ladd's interest in children's problems was as well as an interest in plastic and reconstructive surgery arose from those early days in Halifax, although Ladd would later deny this association. The event still serves in our minds as an activity of pediatric surgery. As many of you are aware, the annual donation of a Christmas tree from the city of Halifax is given a continuing gratitude for the assistance provided by the city of Boston for this devastating event. Ten years thereafter, Ladd spent more and more of his time at Boston Children's Hospital until 1927 when Harvard University and the Board of the Hospital named him surgeon and chief. Ladd would later state and letter to one of his pediatric surgery colleagues that landed Georgia that, as far as the effect of this experience, Halifax, had on my selection of a specialty, I would say it was nil. The children's was my very first and most permanent love. As soon as it became feasible after World War II, I devoted myself exclusively to pediatric surgery and have never regretted it. In 1937, ten years later, office space within the hospital was provided to Dr. Ladd and a grant from the hospital managers in HMS allowed him at that time to limit his activities to Children's Hospital. So, it's apparent another tradition of children's, the difficulty of getting office space existed back at that time. He then was receiving financial compensation and previously all of his work at Children's Hospital had been the charity work. Ladd was known as a meticulous operator using fine sutures. Most of his work in the operating room, he's shown here in his later years, was taken up, caring for difficult, indigent cases. I said, private practice was not large. From the beginning, it appears that Ladd was determined to improve the surgical care of infants and children and to make it comparable to that enjoyed by adults. He felt that most of the surgeons of the day knew little about the management of sick children and less about infants. Thus, they were rarely comfortable with the total patient care particularly with infants. He would state in a New England journal article that those who consider the child is simply a small-sized adult, constantly flirt and frequently suffer disaster. In variations of this, or often quoted, most of us not knowing from where the quote comes. He made recurrent trips to the autopsy laboratory to examine the infants who died of congenital intestinal mal obstruction. Malreatation of the colon and mid-dat volvulus was a particular interest to him. In the 1930s, he devised an operation to minimize the risk of the often lethal volvulus. This operation continues to bear his name and is performed to this day as I think the majority of the audience knows. He also published his results on the treatment of intersception, Judean Latreja, common infections of this time, impyema, astymialitis and appendicitis. Remarkably, he decreased the mortality of staff impyema from 35% to 4% prior to the introduction of any antibiotic therapy. And to think we felt we were making advances when we did this procedure thoracoscopically. Although the etiology of appendicitis was then understood, its mortality was high. In fact, it was the fourth ranking cause of death in children between one and twelve years of age in the 1920s. 60% of the patients presented with perforation. By the 1930s, Dr. Lat reported a series of 95 consecutive cases of perforated appendicitis, pre-soltha without a single death. Remarkable results when you think of the limited resources which were available at that time. Radiology imaging continued to improve with the new technology which is shown here, and we have created in the diagnosis of surgical illness. Additional awards were constructed behind the Hanyuol building. We've shown here, here's the Hanyuol, here are all of the additional hospitals for housing the overflow of childrens. And this included the Ida Smith building which contained many of the surgical patients. The awards here have shown the separation of patients to avoid transmission of infections you can see there's thanks, but I don't see any pure old containers out. Lat's surgical training program was the first in North America and it was designed to rectify the deficiency and the understanding of pediatric surgical problems and to treat total child care of six surgical cases of all ages. In 1941, Dr. Lat was appointed as the first William E. Lad professor at Harvard Medical School. Dr. Lat would become a founding member of the American Board of Plastic Surgery and was a charter member of the American Board of Surgery. At that time, Dr. Lat's senior colleague Dr. Landman who I've quoted previously had joined him in 1927 as an associate in pediatric surgery. His early efforts to repair a soft agiallatrizia included a remarkable report of 32 sequential failures in 1940 which eventually led to Cameron Hates success for the next referral procedure at another institution. So these were remarkable men. How many of us today would dare to submit a manuscript to telling ten of our cases which were failure? Let alone thirty two. Dr. Landman went on to perform the first reported successful numenectomy in his child. He left children to serve in World War II and when he returned he was selected chair of the American Board of Surgery. Dr. Land was the first recipient of the William E. Lad Medal for American Academy of Pediatrics in 1954. Now over Swinson who shown here trained in surgery at the Breggam and Children's Hospital and Dr. Lads' invitation became an attending surgeon at Children's in 1945. He became interested in children with congenital mega colon later known as Hirschsprings disease during his residency. The obstruction at that time was felt to be due to disorganized peristalsis of the entire colon. He studied several patients with mega colon who had to transfer his colostomy and found to my other disappointment the paralysis waves were normal. Later it dawned on me as I observed the beneficial effect of colostomy and after reviewing Bury Minimus for Dr. Newhouse who was a chief of radiology at that time that the problem was a physiologic partial obstruction of the distal colon. Following this simple observation by a prepared mind its dramatic consequences were realized. He adapted an operation to allow resection of the defective distal colon and rectum with creation of an asthmosis of the normally-intervaded colon to the rectal stump. He moved to 1950 to Boston Floating Hospital after he received a note under the door of his office from Dr. Gross suggesting to him that it was time to move on. Nobody's gotten any notes from me. Incredibly Swenson would not be the last to suffer the fullness syndrome at Children's Hospital. But this approach by Dr. Gross would lead to the establishment of outstanding programs in pediatric surgery in Columbus, Kansas City, Cincinnati, Seattle, Washington, D.C., and across town at the MGH all populated by his trainees who were pushed on. Dr. Swenson received the lab medal in 1969. Now Robert E. Gross, whom I mentioned, was born in Baltimore to a piano maker. He sent his son to work with a watchmaker to enhance his manual dexterity and improve his vision in his one deficient eye so that he could carry on the piano business. Gross went to undergraduate school in Carlton College in Northfield, Minnesota before coming to Boston or he changed his trajectory and graduated from Harvard Medical School in 1931. He was shown here at that time. He initially performed a pathology resident with SBIRT wall back at the Brigham, followed by a surgery residency at the Brigham under Elliott Cutler. A portion of both of these programs had been completed at Children's Hospital. Now in 1938, when he was 33 years old and assistant resident in surgery, Dr. Land electrified the world and shocked his chief by successfully ligating the patent ductance of a 70-year-old girl when Dr. Land was out of town on vacation. Don't get any ideas. Dr. Gross had studied the structure in the pathology lab with Dr. Wallback where he saw its devastating effects producing bacterial intercarditis in the high pulmonary vascular pressure injury to the lungs. He cried out from a canicle solution which he devised in the laboratory. And shown here from his atlas pediatric surgery, you see his surrounding of the patent ductus. It's doubly clamping the often very broad and short vessel and here oversawing. He also spent years in active investigation in his laboratory developing methods to build what was called the Gross Well in which he showed in which he sowed a rubber cone on top of the low pressure atrium to which the blood would rise to a low level, but he could then through that opening repair atrial septal defect blindly. He also investigated the surgical repair of the cortation of the order in the laboratory and defined the best method of repair by using the birding sutures as you see here to prevent the development of blood clots within the order. Although clearance Crawford in Scotland would first report the first successful repair of the cortation, it was gross who would develop the use of human aortic alligrapes or homographs to allow longer segments to not segments. And this is really the birth of vascular surgery. He also devised the methods to divide the vascular ring and repair congenital diaphragm, the kernea and skin coverage of the giant emphalusio which was often previously fatal. His doctor Gross shown here was named as Dr. Lads' successor in 1947, only eight years after he had joined the staff, but two years after Lads' retirement. It said that the process took two years because of Dr. Lads' opposition to his session. Fortunately, we didn't have that issue this time. Where did the development of a cardiac pump oxygenator by Gibbons in Philadelphia lead Gross in his college to fashion a disc oxygenator and pump mechanism put together in a compact unit of stainless steel? Obviously, at that point, they didn't have to worry about FDA approval for any of these devices. Thereafter, open heart surgery was performed on children daily, usually two children of a day of a similar blood type. This was done so that the second child could be hooked up to the pump oxygenator without the time consuming removal of blood from the first operation. In our infection control officers and risk management personnel loved that one. After the surgery, children were then returned to a four-bed board for highly intensive post-operative care, which is really the first critical care unit of children's. From 1948 to 1966, the searchable residency at Boston Children's Hospital was a graduated treat to your system. There was a single junior residency or two-year senior residency followed by a year of chief resident. Dr. LaAd, who's shown here, received the Lasker Foundation Award twice. First in 1954, Dr. Blaylock and Tossig, physicians were all familiar with, for quote, distinguished contributions to cardiovascular surgery and knowledge following which the horizons of expectation are now limitless. He then in 1959 received a second Lasker Award for performing the first successful repair of an intrinsic inborn cardiovascular defect. Dr. Gross also received the Bigelow Medal of 1970 from the Boston Surgical Society in the LAD Medal of 1965. In 1946, after returning from the war, Robert Smith, who's shown here with Dr. Gross, was named Chief of Anesthesia, a position he held until 1980. He completed surgical training at Boston City Hospital and was in practice in the South Shore for a short period of time before he entered the Army during the Second World War. In the medical corps, he had a three-month immersion course in how to provide anesthesia. And this was his sole formal training and especially before he took the position at children. So for the anesthesia fellows, we can compact your training remarkably. It is said that he learned the nuances of pediatric anesthesia from Betty Lank, who's shown here. He was a nurse and nestedist who'd been providing anesthesia for Dr. Gross at Children's Hospital for many years at that time. And before Dr. Smith's arrival, during Dr. Smith's time at service at children's remarkable advances in the anesthetic, many children have occurred. While LAD was advancing the field of searching at children's hospital, was faced with the polio epidemics. The Harvard Infantile Paralysis Commission turned to Children's Hospital for help on two fronts, first caring for children who contracted polio and in the effort to find a cure. Children with severe respiratory compromise from the disease were saved of the development of the iron lung by Philip Drinker in 1928 at the School of Public Health. And here you can see his schematic of how the iron lung would work and the very schematic figure, I guess, of a child. He would go on to develop this and I think all of you are aware that there's one of these devices outside in the lobby. In 1946, just before Dr. Gross was named Chief of Surgery, John Enders, who's shown here, was asked to establish a laboratory for research and infectious diseases at the Children's Medical Center. In this laboratory, much outstanding work on the viral diseases of man was performed. And it was here that the work was accomplished on the cultivation of the polio virus for which Enders, which is shown here at the press conference after the announcement, was awarded the Nobel Prize in medicine in 1954. For their discovery of the ability of polio virus to grow cultures and cultures of various types of tissue, which of course led to the creation of vaccines. And Dr. Enders won that in conjunction with Tom Weller and Frederick Robbins, other Harvard physicians. The efforts of Sydney Farber, shown here, was Chief of Pathology of Children's Hospital in the Brigham, must be mentioned as well. He felt that the growth and spread of cancer could be, in some cases, treated with drugs. He reported early success from the treatment of leukemia, and of particular interest to surgeons, was his pioneering use of Jimmy Fun Tree for the treatment of Wilms Tumer. A remarkable response was shown to this agent. This is a little guy who came out of the hills of Maine with a very large renal mass. And on his x-ray, you can see these very large cannonball lesions, which were pulmonary metastases. At this time, that was uniformly fatal. But in this little guy, when Jimmy Fun Tree was first utilized, you can see that after the use of that agent and low-dose radiation therapy, the lesions entirely resolved. And this shows Stephen, just before he disappeared in the hills of Maine, never to be seen again at around nine years of age. So I can tell you, I also went through this little guy's chart, and there's no mention of informed consent from the parents or any of those issues with which we have to deal today. Now, Dr. Farber was very patient in his thoughts and really developed the idea of chemotherapy far ahead of its use for many uses such as breast cancer and colon cancer today. In 1966, he made a statement that adjuvant therapy was based upon the supposition that in children with Wilms Tumer who died, the tumor must have metastasized already at the time of discovery of the primary tumor. Although no evidence of spread was available. And obviously, at that time, they didn't have the CT scan or available that we have to make that accurate diagnosis. In 1955, children's moved to the Farley building, which is shown here, and this is the infant's hospital in the foreground. This updated the physical facilities for pediatric care and replaced the multiple pavilions which had been constructed to accommodate the growing populations. You can see that the crowd in the garden was present at that time. In 1967, when the trustees created a cardiovascular center for Dr. Gross, he relinquished the responsibility for the general pediatric surgical services efforts had increasingly turned to cardiac surgery. He accepted the assignment as a cardiac surgeon and chief until his retirement in 1972. Here is shown with his successor, and cardiovascular surgery, Dr. Aldo Castaneda, who would perform the early primary repair of many cardiac occasions which were previously managed with initial palleted procedures. Only after retirement, the doctor grossed confess that he had operated through his entire career with only sight in one eye. On the medical service at that time, Mary Ellen Avery, who's shown here, was chair. She was a pioneer in the treatment of premature and low birth weight babies. In 1959, she discovered that her fact and deficiency was the major cause of respiratory distress and premature infants. In 1991, she received a national Medal of Science for Research from President George Postal. In 1970, the Ender's Research Building was completed to expand the physical research capacity at Children's Hospital, and in addition, in 1990, doubled the size of that building. Judith Folkman was selected as a new surgeon and chief in 1968. He come to Harvard Medical School in 1953, having completed his undergraduate work in his hometown of Columbus, Ohio, where he'd worked in the undergraduate as an undergraduate in the dog lab of Robert D'Alentia, who is a chief of surgery at Ohio State. He began working in the dog lab with Dr. Gross when he came to Harvard Medical School, and he created the atrial septal defects which Gross would repair. After medical school, he completed a residence at the MCH. Dr. Gross wrote a remarkable recommendation for him, and the letter is up in the third floor offices where he stated that, quote, he has a very high native ability, his extremely industrious, is an alert, highly intelligent, pleasant, and outstanding medical student. He has extraordinary manual dexterity as a surgical operator, and the laboratory has already been doing things which we usually do not find a man until a man is three to four years of medical school, out of medical school. After completing a surgical residency, he was appointed an instructor in surgery at HMS, and in 1965 started working in the serious research laboratory at Boston City Hospital. He'd been instructed by advisors not to stay where he trained as he would always be considered a trainee, what a loss for the general. He made the meteoric rise from instructor to professor in a single bound, with his appointment two years later as chief of surgery at Children's Hospital. It's obvious that the search committee sends the genius of the man to point him to this position at such an early stage in his career. Dr. Folkman shortly after his appointment received a call from C. Evercoup, who was chief of surgery at CHOP, inviting Dr. Folkman to come work with him at Children's Hospital of Philadelphia. Significantly, Dr. Coup had visited Gross at Children's Hospital in 1946 after his chief at the University of Pennsylvania, Isadora Rabden, had named Coup Chief of Surgery at CHOP. So Dr. Coup spent nine months at Children's as an observer under Gross, so Coup obviously returned this favor. He after arrival at Children's Dr. Folkman, shown here established an active research laboratory. He'd postulated, as shown here, that tumors secrete angiogenesis factor which stimulates new capillary of growth. This hypothesis was developed when he was working for two years at the Naval Research Academy and the midst of the surgery program for undeveloping a blood substitute for used in the nuclear submarines. He showed that tumor eyelets placed in a perpused thyroid gland could only grow to a few millimeters in size and yet when they were explained into the animal, they could grow exponentially. This theory was vigorously debunked by the scientific community, making publication and grant funding quite challenging. His initial publication on this topic, tumor angiogenesis and therapeutic implications, appeared in the New England Journal of Medicine as a seminars in medicine article which protected his article from reviews by the scientific naysayers of the day. A figure similar to this appeared in the article and demonstrated his hypothesis once more regarding tumor growth by induction of angiogenesis. But soon his daughters would become his competitors and after the isolation of the first angiogenic factor in 1984, a basic FGF, the field became active and hundreds of publications came from his and other laboratories as shown here when you see the number of publications versus the year. History angiogenesis was established as search for angiogenic inhibitors to fight cancer curve and this figure shows an early experiment on an anti-angiogenic agent which was identified in cartilage, showing its inhibition of new vessel growth. Today angiogenic inhibitors are approved in multiple clinical trials by the FDA for treatment of cancer and macular degeneration. Some members of the faculty in the Surgery Research Laboratory now known as the Vascular Biology Program have become members of the National Academy of Science. Along with Dr. Folk including Bob Langer, Patricia Donahoe, Michael Jimbroney and most recently Marciamoses. Dr. Donahoe deserves special mention as a former chief of pediatric surgery at the MGH. He worked with Dr. Folkman in the laboratory before establishing her own pioneering research known to all to identify malarion inhibiting substance. Perhaps less known as her more recent work, now identifying the genetic underpinnings of the congenital anomalies with which we as pediatric surgeons and anesthesiologists work on a daily basis, particularly like congenital diaphragmatic hernia. She received a lab medal in 2005. Dr. Folkman stepped down from his position as chief of surgery in 1982 to deflate his efforts entirely to his research program until his entirely death on July 14, 2008. She noted that he received a big little medal along with many other awards including the lab medal of 1995. Now, 1990, the Nobel Prize in Physiology or Medicine was awarded jointly to Joseph Murray and the President of the United States of America. For their discoveries concerning organ and cell transplantation in the treatment of human disease. We can't claim credit at children's for Dr. Murray's work in transplantation, which was performed as shown here at the Brigham, leading to the first successful transplant in identical twins. There was a gentleman who was shown leaving the hospital here following the transplantation. But he has made a lifetime contributions to children's and his ground-based surgery to treat children with craniofacial anomalies and congenital deformities. He performed the first mid-face advancement in North America in 1968. And it's possible from this one example slide to imagine the massive impact that this reconstructive surgery had on these unfortunate children benefited in them for their lifetime. Dr. Murray was named the Chief of the Division of Plastic Surgery by Dr. Folkman in 1972. At St. Meade, Dr. Murray invited Paul Tessey, the father of craniofacial surgery in France, shown here to initiate the craniofacial program of children and to work with him on the craniofacial reconstructions. They had a mutually collaborative effort which resulted in remarkable advances in this area of surgery. Dr. Murray has told me that the challenge was not only in completing these technically complex repairs, but factoring into the surgery, the future development which would occur as children grew. He dedicated the last 12 years of his practice to craniofacial surgery. Dr. Murray received a big old medal in 1990. Another collaboration that Dr. Murray was for John Mulliken at Children's Hospital, whom he recruited in 1974. Here he's shown with Dr. Murray and Brad Cannon, who was an iconic figure at the MS General Hospital in Plastic Surgery. Dr. Mulliken was critical to the continuation of the craniofacial program of children's after Dr. Murray's retirement, as well as the continuity finement of the repair of cleft lip and palate deformities, and in co-leading the vascular anomaly center with Dr. Folkman, a field of discovery in which he has been a two-year-old leader worldwide. Dr. Hendren, shown here, came to children's in 1983 as a chief of surgery from across town, where he'd been banished to the MGH. Where he had a long established reputation in pediatric surgery and pediatric urology, particularly with regards to the surgical management of mega-yurder, which is shown here in the undiversion of children with complex urinary anomalies. This led Dr. Gross to comment at the American Surgical Association after one of Dr. Hendren's presentation that, quote, as I reflect on things, it is very appropriate to recall the words uttered so long ago by Leonardo da Vinci, when he said the brilliant student will certainly outshine his teacher. Remarkable statement from the man who forced Dr. Hendren out of this institution. Dr. Hendren was also known for his division of conjoint twins, complete repair of the cloaca anomaly for which no two patients are alive. After his move to children's, he continued his work focusing on the most complex challenges in pediatric surgery, particularly the cloaca, whereas technical versuosity and persistence continued to impact the lives of his patients' decades in lifetimes. Here Dr. Hendren is shown operating with his longtime scrub nurse Dorothy Hinoes. The nurses, in fact, because of the duration of his cases, changed the time units on the clock in room seven from hours to days. He had hanging in his OR, this sign, which had originally been a Dr. Gross's OR, that if an operation is difficult, you are not doing it properly. Although I must confess that this sign was not always correct when it was hanging in room seven. Dr. Hendren received the Bigelow Medal in 2001, the Lad Medal in 1983 for his pioneering efforts in pediatric surgery. Children's has clearly evolved significantly from the time it moved adjacent to the HMS has shown here in the early 20s to the addition of units behind the Honeywell Building, as shown here, and the addition of the Farley Building that you see here behind children's and you notice all of the other hospitals who have gone, units are gone and here was the infant's hospital at that time. This shows the new Berthium Building, which was occupied in 1987. The Inpatient Wards were moved at this time from the Farley Building, an additional clinical expansions were completed in 2005, as well as a subsequent Mandel expansion. The Vascular Biology Program moved into the top two floors of the new carp building in 2003. This shows the Vascular Biology faculty at the time I arrived at children's hospital. And this shows the faculty now. 21 World for Noun Scientists working under the leadership of Dr. Marge and Moses remain active in the identification, both angiogenic and anti-angiogenic substances, and establishing the biologic basis of metastases, as well as identifying the biologic markers of malignant disease, which we hope will be helpful in both establishment of diagnosis and recurrence in patients with malignness. Now we have a deep hole replacing the powdered garden, which will lead to our new Hale Building, which is shown here, which will all further expansion of all of our clinical activities. The current clinical department is shown here as of last spring. We continue to build on the accomplishments of the past and deal with the surgical diseases and cures that our predecessors could never have envisioned. Advances include the use of omega-3 nutritional supplements to treat infants, with a paddock injury developed by Dr. Puder. You can note the dramatic change in this infant between the salo-yellow complexion and the plant-happy grill on the right. As the development of new surgical procedures lead to treatments and infants, children with short bowel syndromes by Dr. Kim with a step procedure, which increases the length and decreases the width of the bowel. The amniotic stem cells removed from the gravity uterus developed by Dr. Fowl's to replace at birth congenital abs and structures. New management paradigms for infants with short bowel syndromes. The program led by Dr. Jack said, okay, if we'll markedly improve their survival, the results in the highest report is survival rates of any short bowel program in the country. Major advances in the advancement and management of infants and children with complex vascular anomalies, such as these have been led by Dr. Fishman or future chair. We also developed the to improve the safety of our patients with active checklist, which have significantly decreased the morbidity and mortality at our center and others worldwide, led by Sean Rungell. We also developed new methods of managing patients with a softagel atreasia, as shown here led by Dr. Jennings, where you can take the softagel remnants, which are not even in the same area codes, and led with growth, reduction can be joined primarily without an interposition graft. Also new methods and manage in the airway of trapeumalasia with posterior trapeal pexid. New methods to reconstruct the abdominal order aorta, amid aortic syndrome, have been devised by stretching the artery with a Tesla procedure developed by Dr. Kim and rerouting the bloodstream through the meandering mesenteric artery with a magic procedure. You can see how that artery, small, added to initial implantation, can grow to replace the stenotic aorta and yet does not become aneurysmal. While socioeconomic environment in which we work is quite challenging, it's obvious from this brief history that not only the institution, but more importantly, the professionals who work within it have evolved greatly in how we practice surgery and cure our patients. While we can enshrine our past, we cannot live in it. The cost of medical care in the United States is the highest in the world. Yet by many indices, our care is below that of many less expensive countries. We must continually assess our current systems of care to improve their results in efficiency. The physical facilities in which we work are not the critical factor, but rather the manner in which we provide care to our patients. Through innovation and discovery, we must continually adapt how we treat disease. In this brief story, we have gone from an arrow where there were no antibiotics to treat infections. Anastasia was provided by medical students and not our stellar anesthetic colleagues today and nurses and medical and surgical tools in Rial and recruited best at that time. Our predecessors successfully treated pulmonary and paemma and perforated appendicitis before the development of antibiotics. Clearly, we must strive to treat the same diseases more efficiently and more effectively with the many resources we have available today. Our predecessors have said, high standards, we must reach and exceed. As we face these challenges, we must remember the admonition of Charles Darwin. That is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change. So I appreciate your attention