One of the founding fathers of neurosurgery and the establishment of the first intensive care unit was born today in 1886. Now WE know em

DANDY (2)

Walter Edward Dandy was born April 6, 1886.

Dandy graduated as valedictorian from high school in Sedalia, Missouri and went on to graduate from the University of Missouri in 1907.

Dandy then enrolled at the Johns Hopkins University School of Medicine, graduating in the spring of 1910.

He then became the sixth appointee to the Hunterian Laboratory of Experimental Medicine where he earned his Master of Arts degree in 1911.

Dandy became a surgical resident at Johns Hopkins in the nascent field of neurosurgery.

In 1913 and 1914, Walter Dandy along with Kenneth D. Blackfan published two landmark papers on the production, circulation, and absorption of CSF in the brain and on the causes and potential treatments of hydrocephalus. Hydrocephalus is the buildup of CSF within the brain, an often lethal condition if left untreated. They described two forms of hydrocephalus, namely “obstructive” and “communicating,” thus establishing a theoretical framework for the rational treatment of this condition. This work is regarded by many as one of the finest pieces of surgical research ever done.

After completing his residency in 1918, Dandy joined the staff at Johns Hopkins focusing his practice on the surgical treatment of disorders of the brain and spinal cord.

 

Contributions to neuroradiology

In 1918 and 1919 Dandy published landmark papers on air ventriculography and the associated technique of pneumoencephalography.

For this contribution he was nominated for the Nobel Prize in 1933.

Ventriculography and pneumoencephalography allowed neurosurgeons for the first time to visualize brain lesions on x-rays.

The importance of this advance cannot be overstated.

Samuel J. Crowe described it as “the greatest single contribution ever made to brain surgery.”

Air ventriculography, however, had the limitation that a burr hole had to be drilled in the skull to pass the needle into the ventricular system.

In 1919, Dandy published a less invasive technique that he labeled pneumoencephalography.

In this procedure, air was injected into the subarachnoid space of the lumbar spinal canal and then the air bolus was maneuvered into the subarachnoid space around the brain and eventually into the ventricles by changing the patient’s position. Ventriculography and pneumoencephalography allowed neurosurgeons to accurately identify the location and size of tumors and other lesions and then accurately target their operative approach.

This technique remained the single most important way of localizing brain lesions until the introduction of computerized tomography (CT) scanning in the 1970s.

Dandy’s surgical innovations proceeded at an astounding rate as he became increasingly comfortable operating on the brain and spinal cord.

 

Contributions to cerebrovascular neurosurgery

An aneurysm is a sac that grows from the wall of an artery in the brain. When an aneurysm ruptures, 50% of patients die immediately and the remaining are similarly expected to die if the aneurysm ruptures again, as it is likely to do.

In 1937, a ruptured intracranial aneurysm was a uniformly fatal condition.

On March 23, 1937, Dandy performed a frontotemporal craniotomy and placed a hemostatic clip on the neck of a posterior communicating artery region aneurysm arising from the internal carotid artery.

The technical prowess involved in carrying out this operation successfully can not be overstated, particularly without the benefit of the surgical microscope for magnification.

Even today this type of surgery is arguably the most complex and riskiest procedure done by neurosurgeons. This represented the first time that a vascular problem of the brain was treated successfully with surgery in a planned fashion.

Dandy’s 1938 description of surgery for clipping of an intracranial aneurysm is particularly important because it marked the birth of the subspecialty of cerebrovascular neurosurgery.

 

Dandy’s “Brain Team”

Dandy established at the Johns Hopkins Hospital a clinical service that served the dual purpose of delivering outstanding care to his patients and also of training surgical residents and fellows to become neurosurgeons. This became a highly orchestrated and efficient system that allowed Dandy to perform over 1000 operations annually (excluding ventriculograms) and produced 12 neurosurgeons who then carried on Dandy’s tradition. Dandy’s service was known as the “Brain Team.” By 1940, Dandy’s Brain Team consisted of a resident, an assistant resident, a surgical intern, a full-time scrub nurse, a full-time nurse anesthetist, an assistant scrub nurse, a circulating nurse, a part-time nurse anesthetist, a full-time orderly, and Dandy’s secretary. The resident and assistant resident each spent two years (out of their eight-year general surgery residency) on the Brain Team.

In 1944, Dandy published a book entitled Intracranial Arterial Aneurysms in which he summarized his experience with these treacherous and technically formidable lesions.

Irving J. Sherman, who trained in neurosurgery under Dandy from 1941 to 1943, addressed his mentor in his recollections:

“Historians are uniformly effusive in praise of Dandy’s research and surgery, but they are less kind with regard to his personality, no doubt because they did not know him personally … Dandy never charged schoolteachers, clergy, other medical workers, or patients who had no money to pay. At times, he also gave money to patients to help them with the expense of coming to Baltimore. … There were stories of Dandy being dictatorial and demanding perfect service for his patients, and these were true. There were other stories, also true, of Dandy having outbursts of temper when “things did not go right in the operating room,” firing assistant residents, scolding personnel, and occasionally throwing an instrument. However, during my time on the general surgery and neurosurgery staff (1940-1943), I never observed such incidents. … although Dandy was at times dictatorial and demanding, his actions made it obvious that he cares deeply for our welfare, although not about how hard we worked.”

 

On April 1, 1946, five days before his 60th birthday, Dandy was hospitalized with a heart attack. He asked his secretary to help him prepare his will, which he signed on April 9 while in the hospital. He was discharged home, but suffered a second heart attack on April 18. He was taken again to the Johns Hopkins Hospital where he died on April 19, 1946.

He was buried in Druid Ridge Cemetery in Pikesville, Maryland.

Outside the hospital, Dandy’s warmth and playfulness were evident in his interactions with his family, friends, and colleagues. His personality is best summarized in his obituary in the Baltimore Sun of April 20, 1946:

“… Gruff of manner, hot of temper, and endowed with a tongue as sharp as his instruments, he exacted awe, respect, and the hardest kind of work from his students. … And when they got to know him well, they found beneath the hard exterior – as is not uncommon in men of such temperament – a deep vein of tenderness.”

 

Now WE know em

 

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