Okay, great. So just by way of background, these are awards for the best presentations from the Pediatric Section Meeting, which was held in Houston this year. Unfortunately, because we are awarding them based on the presentations, we're not really able to determine the winners until the end, so we can't give them their plaque. So we're going to do that here today. So the first award is the Hydrocephalus Award, and as you can see, this is awarded to the best paper presented at the Winter Meeting of the Joint Section by a resident in training on the topic of hydrocephalus. And the award this year goes to Dr. Sean Vuong. Just a little background on Sean. So he is currently the chief resident at the University of Cincinnati. He grew up and did his undergraduate medical school training at the University of South Dakota. Sean is about to begin his pediatric fellowship at Cincinnati, and after fellowship training, he's hoping to return back to South Dakota to practice. For his research, Sean worked under the guidance of Drs. Gatto and Mangano, and he spent one year developing a rodent model of congenital hydrocephalus using CRISPR technology, and they discovered a gene that is responsible for the development of congenital hydrocephalus, which they're now hopeful can be translated to a human model. So, Sean, congratulations on your award. I'm going to ask Dr. Stone to serve as a photographer, because we may be ahead of our photographer here. Dr. Stone has never used an iPhone before, so let me just help him out here. I don't know the code. This is probably not the best background here. We've got extra time, so do you want me to take it up this far? How about Sean? We'll go down here. It's very official here. Congratulations. Dr. Stone, before the next award, do you have that down? You're okay using the phone? Okay. All right, so the next award is the Shulman Award, and as you can see here, this is awarded to the best paper presented at the annual joint section meeting by a resident in training. And this year's award was given to Dr. Derek Yeses, so Derek also gave a very nice talk in the plenary session today for those who were able to see it. Derek grew up in northern California and attended Princeton as an undergrad. He came to Boston for medical school at BU and also worked in the Dana-Farber at that time. And he's currently a PGY-5 at Stanford, where he's completing his work with Drs. Grant and de la Zerta. And his work is focused on translating recent advances in optical coherence tomography into tools that can be used to localize brain tumors. So Derek gave a great talk on this at the pediatric section. Derek, by way of all of you program directors, is hoping to pursue a career in pediatric neurosurgery and did recently also get the Pediatric Traveling Fellowship Award. So Derek, congratulations. Thank you. I think we have this down now. All right. So if we can move on now to the next talk. Okay. This is where we are now, right? Okay. So it is now my pleasure to introduce Dr. Michael Scott, who is going to be our 2000... Wow, the 2108 Mattson Lecturer. Mike, if you could return in 90 years for this talk, I think all of us that would be there to witness it would be really impressed. So, well, since we have him here today, we're going to let Mike give the talk as the 2018 Mattson Lecturer. And it's my pleasure and honor to introduce Mike, who's really been my mentor. Oh, see, here's the official photographer. Skellige, you're off the hook. Actually, I will ask. Sorry. So Sean and Derek, don't leave. Maybe we'll try to get more official photographs after Dr. Scott is introduced. So Mike has been my mentor for many years, and it's a thrill for me as the head of the section to be able to invite him as the Mattson Lecturer. So I just want to give a little background on Mike. And despite my usual tendencies, I'm going to really try and be very respectful here because I respect Mike more than really anyone I've met professionally. So Mike, you can see, went to Williams College as an undergrad. Then he went to Temple University, where his father was actually, by the way, the chair of neurosurgery at Temple. He did his residency at the Massachusetts General Hospital and then started his career at Tufts and really established himself as a leading pediatric neurosurgeon in those days. And then in 1998, sorry, 1988, went over to the Children's Hospital, where he became the division chief with Peter Black as the chairman. And then in 2004, Mike became the neurosurgeon in chief at Boston Children's, where he remained until he stepped down in 2011. Just a couple of things I want especially the youth in the audience to note here. First, lack of facial hair. So these are just some of the things you want to think about as you advance in your career. And this may be the only picture of Mike with a tie, a regular tie. You'll see every other picture going forward, he's converted to a bow tie. So clearly there's something about seniority and leadership where that bow tie made a big difference. So here's Mike over the course of his time with leadership. And you can see that's sort of classic Mike. His glasses have changed a little bit over the years, but not much else. So he has the largest repertoire of bow ties I've ever seen and probably the largest repertoire of leadership positions you'll ever see in pediatric neurosurgery. So Mike had the position I have now, the chair of the joint section of the AANS and CNS. He has been the president of the ASPN. He was a board member of the ABNS. And I will point out at the time that he was essentially the first pediatric board member on the ABNS, something he was very proud of. He's been the chair of the American Board of Pediatric Neurological Surgeons and the chair of the American Council on Pediatric Neurosurgical Fellowships. So that's sort of his official pedigree. And just going a little bit more about what's he like as a person, and I would say Mike is really sort of the consummate pediatric neurosurgeon, both as a surgeon and really as a physician. So Mike is, you know, I think if you were to go around the Children's Hospital and ask people, he is probably one of the most caring physicians you can ever meet. And although he's a technically masterful surgeon, I think what really sticks in most people's mind is just how caring he is and how he always puts the patient first. So we're honored that Mike still will see patients a couple of days a week. He's no longer operating. But as a physician and surgeon, I think you all get to see him in these forums here asking intelligent questions, maybe not the most intelligent one today about finite element analysis, but Mike, I can assure you, as a physician, is just a wonder. I think probably one of the things that's most important to Mike is his role as a teacher and mentor. So this is a wall in our library, in our offices, and you can see here, you know, starting from the very first fellow, that's Ben Whorf in the upper left corner. And Mike was essentially the head of the program through Lissa Baird down here, so through 21 fellows. And I can say that I think 19 of them attended when we had a sort of retirement party for Mike. So you can see folks here, you know, Mark Luciano, Dave Frim, Dave Adelson, really a lot of leaders in the field, Dave Sacco, Ed Smith, Cormac Marr, Paul Clemo, and, you know, that sort of list goes on. Eric Jackson, I think, is here today, Lance Governale. Lissa's here, so Dr. Stone is here, but he really was in a different era, so we won't include him here. But I think this is really what Mike is most proud of, is the legacy of people that he has trained to go move on in pediatric neurosurgery and sort of live on what he taught. Mike has also been someone who can really balance his work life in a way that has been very impressive to those of us that have watched it over time. So he's a huge Red Sox fan. This is actually the official party when he was stepping down as chair and Al Cohn was taking over. And the official gift from the hospital was a formal official Red Sox jacket that sort of monikered with his credentials over here. And here's he and Ed Smith at a baseball game, and a couple of their friends right behind him. Mike is also a big music lover, and this is one of my favorite pictures. I took this picture. I was there. So this is Mike at the Cleveland meeting several years ago. You can tell it's getting wild when the bow tie is undone. I want to point out that this tip jar was actually tips that Mike was getting for playing the piano that night. I would say Mike might not remember too much of that evening. But it was literally, we were just there for hours going on, and people started coming up and putting money in his jar, which I've deducted from his pay since. I remember when I was fellow with Mike and he came in one day and we're operating, and I see he's got this big blood blister on his finger. And I'm like, you know, this was a Tuesday. And I said, Mike, or I didn't say Mike. I couldn't say Mike until about two years ago. I said, Dr. Scott, you know, what happened to your finger? And he goes, oh, I went and played in a band last night with my son. So he had a big blood blister from playing the bass. So this was a Tuesday. So Monday I'd operated with him. He drove to Provincetown, which for Boston is a good two- to three-hour drive, played in a band all night, drove back and was in the operating room the next morning and played long enough to get this big blister on his hand. So the way he's been able to balance his work life and everything outside is wonderful. Mike is a real family man. I know Susan is here today. I saw her in the audience there. So Susan has really been a source of, you know, a lot of support and loving. And, you know, Mike goes out and he will visit his grandkids out in Seattle for the weekend. And really someone who's been, you know, as much as we think of him as sort of the consummate pediatric neurosurgeon, I know he's also thought of as a wonderful husband and father. Now, with all of this said, I don't want to put him too high on a pedestal before his talk here. He'll just sort of float away and won't be able to speak to us. So I want to make it clear, he's not perfect. This is just one episode of Mike being suspected by the authorities of more than we'd like to think. No, this is, I've actually witnessed this several times. Mike doesn't like to go through the x-ray machine at the airport, so he insists on a body search. You can ask him more about that later. But that's it. I was trying to keep it above board there, Mike. He and I, we have a good sense of humor with each other. This is now a portrait that sits outside of our offices, and I think weirded Jeff Wissoff out a little bit when he came a couple of weeks ago, because wherever you walk, it looks like Mike is just staring at you. But it's a huge honor for me to present Mike as the 2018 Matson Lecturer, and I know we're all in for a treat with his talk. Thank you. Thank you. Well, Mark, thank you so much for that very gracious introduction. I hope you'll ditch that picture at the airport. I should have never let you take that photograph. That's for sure. Well, at this stage in your career, everybody always asks you, what was it like in the old days, Grandpa? That's what my talk is going to be about today. I did want to say a few things about Donald Matson, however, if I could. I'm sorry, this is not advancing, Greg. I got it. So I think it's interesting to me how quickly these names that were talismans for those of us in a certain generation are lost with the next generation of neurosurgeons that come along. I mean, what was Matson's importance to the present generation of pediatric neurosurgeons? Well, with Frank Ingram, who was really the father of pediatric neurosurgery, he really categorized and described all of the neurosurgical entities that are unique to the neonate and to the child. And he published accounts of all of these conditions in this classic textbook, The Neurosurgery of Infancy and Childhood. He was responsible for the foundation of pediatric neurosurgery as a subspecialty in neurosurgery. This is the frontispiece of his book. This was a book that was a Bible for all of us for a couple of decades in neurosurgery. I know all of the residents that I work with had it in their libraries. That was published by Charles Thomas, $18.50 for a textbook in those days. So this was a remarkable compendium of all of the spectrum of unique pediatric neurosurgical disorders and how to treat them. He accurately described brainstem tumors, craniofringiomas, craniosynostosis, and his surgical outcomes in that pre-CT and pre-MRI era were really quite remarkable. One of the nice things about this text is how his humanity infuses it, and you can see time and time again examples of how concerned he was about these patients, whose histories and clinical courses he was reporting. They had some lovely things in it, and the primitive ways that they evaluated children in those days. This is a flashlight fitted with a cap that's taken from an intravenous bottle in the old days that they used to transilluminate the skulls of the babies to see if they had hydrocephalus or hydranencephaly. Here's an illustration from the textbook showing a baby whose scalp was transilluminated by one of these and who obviously had the diagnosis of hydranencephaly. This was the way they nursed the babies with myelomeningocele to keep pressure off their backs as their backs were healing after the surgery. I'm not quite sure what this did for the intraabdominal pressure, but at any rate, it was the standard technique of the time. This was his description of constant ventricular drainage techniques, and you'll note that the tubing entering the skull is, I believe, polyethylene, he states there in the illustration, and you'll see this concern about tubing that's used in children's bodies in a moment. I'll discuss this further. But these very primitive techniques were the forerunners, of course, of the ventricular drainage processes that we use today. I love slides like this or illustrations like this from the book, which show a child who at two and a half years of age was quadriplegic with this, what he termed a, I think, a cystic teratoma of the spinal cord, and he followed these children for years as so many of the people at Children's Hospital and my predecessors did. And here is a picture of her at age 18 to the right here. I love the airbrushed diaper on the baby there, which is obviously white-out over the, applied by the textbook people to cover the baby's genitals. So Mattson did attract students from all over the world. His pupils formed their own departments of pediatric neurosurgery, really, all over the world, and there are legacies of his training to this day all over. He just seemed like a gentle, lovely man. He died an untimely death from a progressive encephalopathy in 1969. Harold, Howard Eisenberg was here. I don't know whether Howard is here in the audience now, but Howard was in the department at that time and helped with some of his final publications, and we reminisced a little bit about this. He was at the height of his clinical powers when he rapidly deteriorated with what was later determined to be Jakob Creutzfeldt disease. His death was a terrible blow to his department, to his residents, to his patients. It's interesting to me, he was indirectly responsible for three Nobel Prizes because of the work he did in his associations and his death. At the time he died, his brain was taken for culture by Gadgisek and Gibbs. They were able to transfer his illness to chimpanzees and establish the process of slow viruses in the brain, for which they won a Nobel Prize. The kidneys that he took out for his ventricular ureteral shunts were used by Enders in Enders' lab to grow poliovirus, and Enders won a Nobel Prize for his work on culturing poliovirus in kidneys. And finally, Joseph Murray, who won the Nobel Prize for kidney transplants, practiced on the kidneys that Mattson removed, and Murray won the Nobel Prize for that work as well. It's an interesting trifecta there. There's a nice article, if anyone is interested in reading more about Mattson, this nice article published by Roberta Reeder, Subhash Lohani, and Al Cohen that was published in the journal Neurosurgery Pediatrics in 2015, describes more about Mattson's life. So what about the grandpa part of this story? I mean, my first exposure to pediatric neurosurgery was, as Mark mentioned, with my dad. He was a neurosurgeon who ran the program at Temple University, and I used to help him prepare his talks that he would be giving on the road at the various hospitals in the area. And he would have days of the lantern slides that were four by five in those cases, and I'd have to change the slides and arrange them for him, and I got my first exposure to neurosurgery by helping him. It was easy to see how concerned my father was about his pediatric patients, and also to see how many conditions there were that the neurosurgeons in that era could not treat. He was very enthusiastic, however, I remember when I was a teenager, about treating hydrocephalus and thinking that there may be a way of treating the children with hydrocephalus. The big problem was the tubing. They could not find any tubing that stayed in the body, did not crack or break, and they tried everything they had available to them. I think my slide here includes Portex polyethylene red rubber catheters. This is from his article in 1955 on shunting of children for hydrocephalus. It was published in the Journal of Neurosurgery, and I love the colloquial language here. He says, one might challenge our judgment in operating on some of these obviously hopeless cases, particularly those in which the hydrocephalus was associated with a myelomeningocele. In every instance, the parents were acquainted with the experimental nature of the operations and the unpredictability of the results, and they either wanted the procedure done to keep their child alive or to help others with similar conditions. And it was interesting that in 1955, the year this paper was published, John Holter's son Casey was born with hydrocephalus. You all know the story about the development of the first valve, which was inserted by Spitz in 1959 at CHOP in Philadelphia. So he was just a little bit ahead of his time with the right tubing, and that made the difference. The diagnostic tools of that era to work up hydrocephalus. This is again from that article. This is a bubble air ventriculogram with the child's head on the right turned upside down. Air fills the posterior fossa there. They knew this child had communicating hydrocephalus. They could use a lumbar shunt to treat this baby. I love this picture. The caption on the photograph says, that was the picture of the child we just saw here. Child now four years old. He is alert and appears nearly normal for age. I think it says normal for age here. I think they sort of ignore the braces on the legs and a few other things in the photograph that this child I don't think looks completely normal to me. This was an interesting technical innovation that they tried. Notice first of all the direction of the shunt in the lumbar theca going downward. This is polyethylene tubing. In the end of the tubing, the abdomen is surrounded by a little cage to keep the end of the tubing from penetrating the viscera. It was sort of like the cage that one might use now in spinal surgery. And the treatment failures they had were many. This is a case where the shunt ended up completely in the head. I had one of these in my first couple of years in practice, I recall. Maybe some of you in the audience have seen this as well. So neurosurgery would be my career choice, but where to apply for a residency? There were no residency matches at that point, and the way you got a residency was just keep calling, keep calling, keep calling, try to get an interview, and hopefully somebody would give you a return call like an audition for a movie. I don't think there was a casting couch, however, at that time. One of the most impressive moments during that period of time where I was interviewing was a visit to Boston Children's Hospital in 1967 when I was an intern. John Tu, who was a resident then at the Mass General, was running the service as a rotator over at Boston Children's Hospital for a year. And he took me around and we saw all the patients on the service then. There must have been 60 patients. He knew them all and knew everything about them, and I remember being impressed, first of all, at the hospital and impressed with John's ability as a doctor. I got a chance to see Mattson operate in the amphitheater that they had at the Brigham as well, looking over the glass partition there and down over his shoulder to see the surgery he was doing. But it was interesting that Boston Children's Hospital then and the Brigham were doing less than 300 cases a year. They never gave me a call back, and I ended up at Mass General, and I think the only reason I got my residency there was because Tom Ballantine, one of the senior surgeons, was interested in jazz, and I gave the right answers to who my favorite musicians were, and I got the residency. So what was pediatric neurosurgery like in that era? Well, in the late 60s and early 70s, pediatric neurosurgical cases were directed to the youngest member of the staff, probably without exception, in almost all services around the country. There were very few neurosurgeons who were known or wished to be known as pediatric neurosurgeons in that time. Most of us had to take care of adult patients at the same time we were doing our pediatric cases. When I started out at Tufts Faculty in 1974, I had to do four months every year at the Jamaica Plain VA, which gave me experience that was quite interesting and very helpful for my career, but not exactly what I had signed up for. We had no CT, we had no MRI, we had no image guidance at all during residency. Our diagnoses were made on the basis of history and neurologic exams, pneumoencephalograms, myelograms, radioisotope scans, and direct puncture carotid arteriograms. So here's our quiz for the afternoon. Here's a pneumoencephalogram on a child with an endocrine disability, growth delay, and I think maybe you can see here, here's the cella enlarged, here's the tumor outlined by air, and you can see calcium within it here, the pituitary stalk in this area, the craniopharyngioma. It's very interesting, this girl, I took her tumor out as a resident, took it to the laboratory at a tissue culture lab there, grew her tumor in culture, one of the rare cranias we could grow, and it grew cholesterol crystals, which was a fantastic finding. Here was an air ventriculogram on a patient with something wrong in this hemisphere. You can see the ventricular system shifted to the right side here, and this is what we had to go on to plan an operation. This was a fantastic case that I took care of in 1975, a patient whose parent had had tuberculous meningitis, and the boy developed tuberculous meningitis and got quite sick from it and then recovered and gradually lost his vision. This was a pneumoencephalogram that was carried out when his vision was lost. You can see the cella here. You can see this thickening of the optic chiasm region. Here's the anterior third ventricle pushed back a little bit. And this, we thought when we operated on this patient, this would be a tuberculoma. It was tuberculous optochiasmatic arachnoiditis. When we operated, we actually could strip the scar off the optic nerves and chiasm, and the boy got his vision back. It was a spectacular case, for which I was written up in the National Enquirer, surgeon restores sight to blind boy. This is a true story, and I got many, many inquiries thereafter from people who lost their vision, unfortunately, permanently. So what was pediatric brain tumor surgery like in the late 60s and early 70s? Well, a child suspected of having a posterior fossa brain tumor would be taken to the operating room first to get a burr hole in. Then after the burr, while the child was under anesthesia, the child would be brought down to the radiology department for an air or a pantopaque ventriculogram. Pantopaque was a viscous, oily, contrast medium that would be placed into the ventricle by a needle. The child's head would be tilted, flexed to guide the contrast material down through the ventricular system to see if the aqueduct was blocked, or if it was shifted, or if the fourth was blocked or shifted. Red rubber catheter with a stopcock, typically a Scott cannula, which was another one of my dad's inventions, a red rubber tubing that had a stopcock on it that you could temporarily drain and close, and it's still in use in some operating rooms, believe it or not, was left in place for ventricular drainage, and then the child was taken back to the operating room for surgery in the sitting position, probably about noontime, for an operation that would then last about six to eight hours. It was a pretty long and exhausting day for all concerned. Here's an example of a pantopaque ventriculogram on the left here. You can see the needle, the dye in the third ventricle here, the suprapineal recess, and the blocked aqueduct here. This told us there was something wrong in the posterior fossa. That's where we should operate, but it told us little else. Here is another air ventriculogram, and you can see air in the lateral ventricles, and this arrowhead points to the fact that air is stopped here at the aqueduct, again, nothing getting into the posterior fossa, so we knew that there was trouble in the posterior fossa. Often we didn't know exactly where the tumor was. The brain surface would be looked at. We did as wide a craniotomy as we could, so we could see as much as possible. We would look for gyrus discoloration or foliar discoloration or distension. We would palpate the brain with our fingertip to see if we could feel any resistance or ballot assist. Then we would needle the brain with a 12 to 14-gauge needle to see if we can feel areas of resistance or maybe hopefully tap assist or detect changes in consistency that might indicate there was an underlying tumor. Another thing that's been interesting to me about this is that many of the operations we carried out in that era are now outmoded or superseded by better technology, and the same thing is going to happen to all of you in the next decade or two, and many of the procedures we're doing now we're not going to be doing. It's interesting to me we had a whole business of lengthening short shunts. Everybody who put a shunt in a baby put a very short amount of tubing in the peritoneal cavity. It was a land office business and annuity in those days. We did open operations. The interesting thing to me about pineal tumors is how that philosophy of their management changed. When I was a resident, we didn't operate on a single pineal tumor. We were afraid to death, afraid of the operative territory. They were all radiated, all comers, because that's what they did in Japan. Then Ben Stein came along and popularized the approaches to the pineal tumor. We began operating on them, and now, as you know, many of these are managed by ETV, biopsy, and adjuvant therapy. So it's interesting to see the way this therapy is cycled. Hypothalamic optic system tumors, we used to operate on and try to do radical operations on them, ignorant of the involvement of blood vessels within the tumor, the involvement of other structures of the base of the brain, and so on. We used to biopsy or attempt to remove hypothalamic hematomas that were causing precocious puberty. Medicines to take care of them now. Craniotomy for supercellar arachnoid cysts, managed by ETV. Craniotomy for vein of galen malformations, an absolutely frightening operation on very sick young babies. Thank God we don't do that anymore. Torkelson shunt, ventriculocysternal shunts, a way of getting around the blocked aqueduct that's now dealt with by ETV. No longer done. And one of the interesting things when I would make rounds with John, too, and see his patients is see the children being tapped for chronic subdural hematomas every other day, and the specimens of the fluid taped up to the bedside sequentially, so you could see the fluid clearing over time. I wonder what's happened to those patients. There was never any consideration for chemotherapy in any brain tumors when I started my practice. We thought the oncologists were dangerous and did not consult them on our patients. That was almost a rule. So what affected the biggest change in neurosurgery practice during my era? And I'd say it has to be imaging. And it also has to be the computer age with the development of computer technology. I showed some of you this image before, but I think it's worthwhile showing to perhaps some of the younger people in the audience who haven't seen it. When I was, I've had a lifelong interest in cavernous malformations, but when I was a resident, throughout my residency, I never operated on a single cavernous malformation, never saw one, until the CT scan came to the Mass General in 1973, during the last three months of my chief residency. We had this young man come into the hospital with a field cut, vomiting, a bad headache, and we thought he must have an AVM that ruptured. We did our standard diagnostic technique. We did a carotid arteriogram and a vertebral arteriogram. The study was negative. The CT scan had just been installed, and I begged them to study this young man in the CT. Here was the ME scan that was done in 1973 on this patient. This is an 80 by 80 matrix, and you can see how crude those scans were, but it was good enough to show us the hematoma here in the left parietal occipital region. Now, I'm sure you're thinking, he just said left, and this hematoma's on the right, correct? No. In those days, what was left on the scans was left on the body, and that was the way that we looked at scans for the next 10 years. To this day, every time I look at a scan, I have to say, right is left, left is right, because of that early training that got me off on the wrong foot. CT scan was then used to study many of the pediatric neurosurgical conditions that we didn't understand well. We used it to study spinal dysraphism, cerebral cysts, and the cavernous malformations vascular supply. This was an early paper we wrote on the use of metrizomide ventriculography and CT scanning to help us decide what the cysts were connected with, and if we could determine more about where the blockages were so we could tailor our operations. This is an illustration from one of the ways we studied cavernous malformations. Cavernous malformations are angiographically occult, and the question is how did they get their blood supply, and why were they angiographically occult? In this early CT scan study, dye was rapidly infused into the patient's vein, and we plotted the appearance of the dye in the normal brain and the appearance of the dye in the cavernous malformation. We noticed that in normal brain, the dye peaked very rapidly and fell off rapidly, whereas in the cavernous malformation, it slowly built up over minutes, sometimes as long as 15 to 20 minutes as this venous drainage got into the malformation. A very early depiction of how malformations obtain their blood supply. Here was a metrizomide myelogram on a patient with a tethered cord. And this patient had a, you can see the cord shadow here in white coming all the way down here and then deviating off to the side where there was a lipoma. Then we studied these kids with CT scanning. This was a patient who had a lipomeningocele. This is the actual scan. There's nothing doctored about this. This was the appearance of the bone on that CT scan. You can see the spina bifida here. And you can see what we interpreted to be CSF here and lipoma here. This was an Ohio nuclear delta scan. This was the first scan that they had at Tufts when I got there. And we used it to study everything we could get our hands on. Here's another patient with a tethered cord. This was a kid with a fatty phylum. You can see the funny configuration of the posterior part of the laminae and this tract extending out subcutaneously, which was something we had never seen before on imaging. Now MRI came along. At least it came to Tufts in 1985, 1986. And all of a sudden clarified for us many of the things we could not understand. Now I had done, and probably many of the senior neurosurgeons in the audience had done, decompressions for Chiari 2 malformations. We operated a lot on babies with myelomeningocele. We're having respiratory difficulty, swallowing difficulty. And when we operated, we got exposures like you're looking at here. We didn't know what the heck, or at least I didn't know what the heck I was looking at. It was very distorted anatomy. We knew from our autopsy specimens that kids with Chiari 2 malformations had very foreshortened posterior fosses and large foramen magnums and wide open tentorium. But we did not understand these relationships until we could see on the MRI how the tentorium was altered and how small the posterior fossa was. Here's a normal child with a, you can see the slope of the tentorium here and the appearance of the fourth ventricle. And here's a child with a Chiari 2 malformation, this very short, stubby, vertically oriented tentorium here. The cerebellum just mushrooming out of the posterior fossa. And you can see the fourth ventricle down here into the cervical cord. This is a child, again, with a Chiari 2 malformation. And I remember being taught as a resident that in the Chiari 2 you see beaking of the colliculi, and that was just something you see. The MRI showed us that the problem was that the cerebellum was so pressed out of the posterior fossa that it was invaginating up against the collicular plate and deforming it by direct pressure, something we did not understand before. Look at the underdevelopment of the corpus callosum here and all the other anomalies that all of a sudden became clear to us. This child, Megan, was one of the early children that we studied who was having terrific brain stem difficulties. We realized, finally, that surgery was never going to help this child. This would have been a child we would have operated on because of her disabilities at birth. But you can see that her brain stem is incredibly stretched out, her collicular plate is, and the cerebellum is just a stick that extends through the foramen magnum here. Very interesting, I got an email about her yesterday. She went into renal failure now at age 36 and has had all comfort measures withdrawn. After spending decades in a motorized wheelchair, a life that I don't know whether was worthwhile living for her, but was very difficult for her caregivers. One other thing I wanted to talk about, too, was mentors. One of the things that really never changed throughout my time in neurosurgery has been the importance of mentors. Mark mentioned it in his very gracious introduction when he brought me up on stage here. In our day, I don't think we called the people who are our teachers mentors. That word sort of came into fashion about two or three decades ago, and it's really stuck with us. But, you know, these people have been very important to me over my career. I've mentioned my father many times, the surgeon teachers I had during residency, my chief resident. Probably many of you, your chief resident was very important for you. Bob Ogerman was a master surgeon at the Mass General. Miller Fisher, a master neurologist who taught me about stroke. My first job boss, Ben Stein, who taught me really how to be a surgeon, how to place and hold retractors, and how to use instruments gracefully. My colleagues at Tufts, Ben Stein, Cal Post, who were a trusted team of expert neurosurgeon teachers and friends. My colleagues at Children's, Joe, Lily, Mark, Ben, Ed, and Skellig. We all teach each other, I think, at a certain stage in your career. And our fellows and students over the years, and Mark has mentioned them and showed their picture earlier, too. I think all of you, my colleagues in pediatric neurosurgery, I think when we all get up and we talk about these problems at meetings, we all learn from one another. And I think that's one of the most wonderful things about the pediatric neurosurgical community. This is a picture of my dad. Chuck Rich, my chief resident. Bob Ogerman. Of course, the uncle to Jeff and Steve. Miller Fisher on the far right there. This is a group at Tufts. Myself on the left, Ben in the center, and Cal Post on the right. Our group at Children's Hospital. Skellig isn't in this picture yet. This is pre-Skellig. And our fellows, who Mark has talked about. It's very interesting. I learned so much from our fellows. Jody Smith, who's here, right here, for example, is responsible for my endowed chair in pediatric neurosurgery at Children's. I had a very difficult case, a cystic tumor in the midbrain that I had operated on twice and was unable to get the tumor out. It was the neural nodule. It was a cystic astrocytoma. The neural nodule was right up against the peduncle anteriorly in the midbrain. I could not reach it. Jody came as a fellow when this kid came back with a cyst recurrence, and we tried to figure out what to do. And Jody said, you know, in Utah, Jack Walker and the team, they used this YAG laser with a micro-dissector on it. Maybe we should give that a try. We got the company to bring the YAG laser in, and we got the tumor out completely. It turned out the family was extremely wealthy. We didn't know that. And they donated the money for my endowed chair, and I owe that to my fellow who brought this new knowledge to me, something I had no experience with whatsoever. So some observations regarding pediatric neurosurgery made over these five decades of practice. Conditions that we considered surgical at the start of our career may no longer be operated on within a decade or two. I mentioned that. It's always been interesting to me how the new procedures have been greeted with skepticism. I think of Peacock's selective dorsal rhizotomy. People thought he was crazy. Then the rhizotomy came into being, and now it's been altered and modified, and baclofen pumps are here. Radio surgery for AVMs absolutely derided in one area of Boston when I was a resident, now commonplace. The use of lasers, as I mentioned, how important they were to me and how common they are for all of us in neurosurgical practice today. Endoscopic procedures, ETV and so on, all of these met with great skepticism when they first appeared and then became widely adopted. I also learned that taking a patient to the operating room is an irrevocable decision that may have far-reaching and possibly undesirable consequences, and I've always tried to talk our residents and fellows into conservative management of the patients until surgery proves necessary. Consulting with colleagues on difficult cases almost always is rewarding. Attendance at national meetings, and I mentioned how important it is to have the interactions we all have with each other at these meetings. So I've mentioned about careful management of many of these conditions while following the patients for a bit and then deciding whether or not surgery is necessary. And you also tend to become, if you're an expert in something, you tend to use that tool for all the patients you see, and we have to be careful about that. Teaching is a part of our tradition in pediatric neurosurgery, and that hasn't changed over the past five decades. Teaching the residents, fellows, our nurse practitioners, PAs, it's a wonderful two-way street. It's interesting, I've set a new second career in coaching in the operating room, and that's been also very interesting to see how our colleagues carry out procedures and what things we all can learn from one another. And finally, we influence our students and the people we work with much more than we know or we understand. Amazing, the occasional compliment that you give to somebody they may never forget. When I was a resident, I did not receive a single compliment or comment throughout my five years as a resident, except I remember one time I was yelled at in front of everybody. I've never forgotten that. But one time I was operating, when the microscope was just being used, I was operating with Ray Chelberg, and after the case he said to me, you know, you have good hands, and I never forgot that compliment. It's the only time anybody in my residency ever told me that I was a competent surgeon, and it makes me understand or realize how important the comments we make to our juniors are to them and to their futures. So we all know it's important to have interests outside neurosurgery and to plan what comes after our neurosurgical careers. Mark has always mentioned how important music has been to me and how frequently I get a chance to play in Boston, and I'm sure that any of us in this room can cultivate new interests or rekindle old ones when the time comes to stop neurosurgery. This is our jazz band we played last night at the reception. These are all distinguished neurosurgeons. We have a great time together, and it's a wonderful way for me to relax, and one of the wonderful parts of my career at present. I want to thank also my wife, Susan, who is here. I said I wouldn't say she was the wind beneath my wings or whatever that is, but, no, but Susan has been a tremendous support to me throughout all of this time, a pediatric neurosurgeon at the Children's Hospital, and I'm very grateful to her. And, Mark, I'm very grateful to you and to the executive committee for proposing me for this speech. I think the world always thought the world of Matson, and to be able to give this lecture in his honor is a great privilege to me. I thank you and the executive committee, and I thank you for allowing me to give this presentation. Thank you.

pediatric neurosurgery

advancements

mentors

imaging technology

surgical procedures

conservative management

teaching

challenges