When one is called upon to prepare a paper for this Society, one naturally casts about perhaps for an individual who is in some fashion close to his specialty. There have been two giants in neurosurgery: Harvey Cushing and Walter Dandy. Cushing has been discussed before this group by Dr. Spurling. John Fulton has written an extensive biography on Cushing. It seems to me that Dandy has been a bit neglected, and some highlights of his career it seemed would be worth retelling. Some of this information will not be new to you. I have had the opportunity to discuss Dr. Dandy with several friends of mine who were former residents and interns under Dandy, and their accounts of this man are fascinating to say the least.
Walter Dandy was born in Sedalia, Missouri, on April 6, 1886, the only child of John and Rachae1 Dandy. His parents had emigrated from Barrow-in-Furness, Lancashire, England. His father was a railroad engineer. Dandy attended public school in Sedalia and entered the University of Missouri in 1903. He found it necessary to earn most of his expenses, and he did this by serving as a laboratory assistant to W. Q. Curtis, the professor of zoology. This was Dandy's exposure, to the scientific methods and stirred his interest in medicine. On graduation from the University of Missouri, he was offered a Rhodes Scholarship but, since at that it was not possible to study medicine at Oxford, he declined the scholarship. In the fall of 1907, with the help of Professor Curtis, he was admitted to the Johns Hopkins Medical School.
Because of his work with Dr. Curtis, he was admitted to the second year class. He was graduated in 1910, standing high in his class. A classmate, Dr. L. Whittington Gorham, relates that Dandy was extremely hard working and took little time out for the Saturday night convivialities which took place on Broadway between Monument and Jefferson Streets. As an example of Dandy's efforts in medical school, Professor Mall 1ad received one of the youngest human embryos which had been discovered up to that time. He entrusted its study to young Dandy in 1907, and in Dandy's senior year he published his first paper - A Human Embryo With Seven Pairs of Somites Measuring About Two Millimeters In Length. In embryological literature this is still referred to as the Dandy embryo.
Dandy has attracted the attention of Dr. Halsted during his senior year and was se1ected by Halsted for further training in surgery. His first year was spent in the Surgical Hunterian (or Dog House). There he came into contact with Harvey Cushing. Work in the laboratory was understood be along neurological lines, but Dandy became interested in the problem of absorption from the pleural cavity. Since this was not a neurological problem, there developed a conflict of personalities which made Dandy's service with Cushing extremely arduous and accounted in part for the feelings which existed between the two men.
Dr. Dandy's hospital service the following year as Cushing's assistant was not a very pleasant or agreeable one. Before the year was finished Dandy was forewarned that he would not be included in the group that Cushing was taking to Boston. Dandy himself recalled that Cushing and he came to loggerheads over experiments on the relation of the sympathetic nervous system to glycosuria - he had obtained results contrary to those expected by Cushing, and this was unheard of. Another account has it that the quarrel occurred when Dandy was assisting Cushing and attempted to do something with his left hand which drew from Cushing the remark, "Use your right hand, Dandy; you are clumsy enough with that.” In any event, Dandy be1ieved that he had lost his position after the quarrel. However, after several months of uncertainty, Halsted found a place for Dandy on the surgical service. Cushing left the Johns Hopkins in 1912 to accept the Chair of Surgery at Harvard. Dandy then began his remarkable development of neurosurgery in Baltimore.
Dandy's entire career was spent at Johns Hopkins. During that time he wrote 169 articles and some six books. The majority of his publications were solid contributions to the field of neurological surgery. With Blackfan he published classic papers on the circulation of cerebrospinal fluid and the cause of hydrocephalus. He originated the technique of ventriculography in 1918 and which we in neurosurgery still use. Incidentally, for you general surgeons, Dandy was the first man to have discovered that a perforated viscus gave a shadow of air beneath the diaphragm when an upright x-ray of the abdomen was made.
Dandy removed the first acoustic neurinoma complete1y in 1917. The operation was done while his surgical chief, Dr. George Heuer, was out of town. By a curious incident, in the same year Cushing published his classic monograph Tumors of the Nervous Acousticus, in which he made the following statement: "I doubt very much, unless some more perfected method is devised, whether one of these tumors can safely be totally enucleated." In 1922 Dandy made preliminary report on total extirpation of acoustic nerve tumors. Cushing wrote Dandy a strong letter stating that he felt Dandy had deliberately avoided mention of the monograph on acoustic neurinomas he had published n 19l7. Dandy was very much offended and felt that in a preliminary report it was not customary to site the literature and, furthermore, Cushing had never attempted total extirpation of an acoustic neurinoma. In 1925 Dandy re~0rted seventeen cases in which he had done total extirpation of the tumor.
Dandy was fascinated by any vascular anomaly of the brain and was a pioneer in the attack of arteriovenous malformations and intracranial aneurysms. He was the first to carry out intracranial section of the ninth nerve for glossopharyngeal neuralgia. Formerly peripheral neurectomy had been done with most inconsistent results.
He became most interested in the problem of herniated intervertebral discs. It is felt by most neurosurgeons that here he went a bit overboard - he described a "concealed disc" in which there was only a slight bulge with thickening of the spinal ligament, thus Dandy never made a negative exp1oration for ruptured disc. To attempt to discuss all the contributions of Dr. Dandy would be impossible in the space of the short time allotted. His papers on the treatment of brain abscess by tapping, air myelography, spasmodic torticollis, intra-ventricular tumors, trigeminal neuralgia, and experimental epilepsy and all classical contributions to surgical knowledge.
The physical appearance of this man was far from prepossessing. He was a rather short individual with mildly slouching shoulders and a somewhat prominent abdomen. His two hobbies were golf and bridge, although in his younger days he did play some tennis. He played golf on Thursday and Saturday afternoons and bridge on Wednesday evening. It was as a result quite easy for the resident to have a fair idea of either his bridge score or his golf score on the day following, and it was common practice for the resident staff to pray for birdies, eagles, and grand slams.
The resident on Dr. Dandy's service would arise at six o'clock and make rounds on the more seriously ill patients. At seven a quick breakfast could be obtained when the dining room opened. A longstanding feud with the operating room supervisor prevented any patient from being brought to the operating room until promptly at eight. The patient was quickly placed on the table and preparation made by the resident. On most mornings several sets of burr ho1es were made for later ventriculograpy and the first case started. This was frequently a tic or a Meniere's syndrome. Dr. Dandy would arrive at the hospital promptly at nine and park by the fire plug in front of the emergency room. Dandy was frequently reprimanded by the police for parking at that particular spot and his answer was always, “I can park my car beside my hospital anywhere and anytime I want to.” The police finally gave up on him.
After parking his car he would go immediately to the operating room, and the resident would tell him as he stood in the door about the sick patients. They were designated as “the man with the frontal lobe tumor from Pittsburgh” or “the lady with the acoustic neurinoma from Wheeling”. He would then change clothes, go into the operating room, section the nerve or remove the tumor, and drop out. Then he would inject the air for the ventriculogram of the next patient, study the ventriculograms in x-ray, and thus determine the order of the next case.
Operations were usually finished about two or three in the afternoon, and the resident would then work up the new patients. At about 4:30 Dr. Dandy’s secretary would call and state that Dr. Dandy was on his way to Halsted 7 which was the neurosurgical floor. Complete rounds were then made with the resident staff and frequently the intern would tag along behind. Each patient would be discussed by the resident as “the woman with the tic from Tallahassie” or some similar designation. A stop would be made at the pathology laboratory for a look at recent specimens and slides. Dr. Dandy would then be escorted to the emergency room door, and just before leaving he would filch four or five cigarettes from the senior resident. He had promised his wife that he would not buy any cigarettes but had a carefully planned system to get around this promise; the resident bought them for him.
After Dandy left the hospital, the resident then returned to the ward to finish the work-ups. At seven o'clock the resident called Dandy to discuss the cases and establish the schedule for the following day. On Sunday nights the call was never made until 7:30 for he always listened to Jack Benny and would not accept calls during that time. At 2 a.m. the resident or assistant resident again made rounds on the sick patients as Dr. Dandy would frequently call in the middle of the night and ask about “the man from Pittsburgh” and he wanted to know his two o'clock temperature and not his twelve o’clock temperature.
Dandy was somewhat deaf, but his residents felt that his deafness was quite convenient for he seemed, to hear what he wanted to hear. One day Dandy's son came to the operating room and fainted at the rather profuse display of blood. Dr. Ed Stafford, the resident turned to the assistant resident and in a very low voice, almost a whisper, said, “Not a chip off the old block, is he.” Dandy said nothing but a few minutes later caught Stafford in an error and suggested that he would be a better resident if he would tend to his work and not make wisecracks. Dandy's deafness was confined mainly to his right ear, and it was necessary to walk on his left. He spoke in a very low voice and would never repeat himself, so that it was necessary to lean toward him, but one absolutely never touched him, thus the resident walked with his head tilted to the right, never swinging his right arm. Even to this day one can distinguish Dandy's old residents by the peculiar crab-like gait they possess.
Dandy was gifted with a diagnostic sense that few physicians have been granted. On one occasion a patient had been checked by a number of physicians including Dr. Frank Ford, the outstanding neurologist at Hopkins. Dr. Dandy stood at the foot of the bed and talked to the patient a few moments and then stated that he would take out the tumor the following day. He informed everyone concerned that the patient bad an acoustic neurinoma. The resident asked him how he had arrived at the diagnosis, and Dandy said, The resident asked “Didn't you notice that he didn’t blink his right eye.” The next day a right acoustic neurinoma was found and removed. Dr. Samuel Crowe once asked Dr. Frank Ford how Dandy could make such precise diagnoses, and Ford replied, “God whispers in his ear.”
Dandy was not greatly interested in clinical meetings. The only major societies to which he belonged were the Southern Surgical Society and the American Surgical Association. On one occasion at the Southern Surgical Society he presented a paper on herniated discs. A rather prominent orthopedist challenged his findings and was quite vehement in his remarks. Dandy, in his rebuttal and closing remarks, suggested that jackals are always snapping at the heels of the lion, and this ended the debate rather promptly.
Dandy's relationship with other neurosurgeons was quite strained He did have a warm personal feeling for Gilbert Horrax, Claude Coleman, Winchell Craig, Francis Grant, and Jefferson Browder. The remainder of the neurosurgeons he either grudgingly tolerated or utterly disdained. He once said that if he ever developed any head trouble in Boston or New York and Browder wasn't around, he wanted to be packed in ice and shipped back to Baltimore. Dr. Charles Troland tells about presenting a patient from Philadelphia to Dr. Dandy who had previously been operated for a brain tumor. X-rays of the skull showed the head to be completely studded with silver clips. Dandy quietly asked, “Did Francis Grant do this?” Troland then informed Dr. Dandy who the surgeon was, and Dandy's reply was, “Hasn’t that dumb little ass heard of the bovie yet.”
Dandy lived very simply. His tastes were not expensive. His fees were quite high, and he insisted on full payment from all who were able to pay. On the other hand, he would at times pay the hospital expenses of many ward patients. He was most generous toward his residents and during Tro1and's last year gave him $600 at Christmas and $500 when he left Dandy's service for the Army. He frequently helped medical students who were in need o£ financial aid.
At times Dandy was quite petty. There is the story of the picture of Dr. Eldridge Campbell which illustrates this. Dr. Dandy's waiting room was adorned with the pictures of his former residents. Dr. Campbell wrote a paper on the removal of foreign bodies from the brain, and in the paper he unfortunately omitted reference to a paper by Dandy. Following this slight, Dandy turned Campbell's picture to the wall. The cleaning woman would come in and turn the picture back, and the next day Dandy would resolutely turn the picture to the wall again. Dr. Campbell was finally appraised of the situation, wrote a letter of apology to the old man, and his countenance once more faced the waiting room.
Dr. Dandy was a great believer in the seniority system, and the chain of command was of great importance. A fascinating story is related by Dr. Charles Troland, I and quote him. “I happened to be the resident at the time and Frank Otenasak was assistant resident. Colley McCarty was the intern who was just about to leave the brain team, and Herb Sloan was the intern who was coming on the team. That particu1ar morning Dr. Dandy asked me if we liked baseball, and upon being assured we did, he invited us to go to the game. The previous resident, Dr. Kenneth Pickerill had agreed to cover the service for the afternoon. The four of us met the Professor at the game and started to go into our seats, but Dr. Dandy carefully arranged us with himself at one end, myself next, then Otenasak, then McCarty, and then Sloan. When the concessionaires came around, Dr. Dandy, Otenasak, and myself were given beer, but McCarty and Sloan got Coca-Colas. I was given two hamburgers, Frank Otenasak got one, and McCarty and Sloan got a hotdog each and I think the old man would have preferred it if they had split one.”
Dandy was a veritab1e tyrant in the operating room, and the slightest deviation from perfection brought down his wrath on whoever was responsible. On occasion he was very tender. On one occasion the resident had had difficulty with a tic operation, and the patient had died. The resident was obviously very distressed and depressed about this. That evening he received a call from Mrs. Dandy to meet the professor at the emergency room door. Dandy called the resident when he came out the door and asked him to sit beside him in the car. Nothing was said for few minutes; then Dandy said, “Don’t worry - these things happen to all of us.”
Dandy died in Baltimore on April 19, 1946, of a sudden and massive coronary occlusion. While his operative skill, his courage, and his personality were extraordinary, it is not because of them alone that he ranks as one of the great masters of surgery, but his fundamental contributions to surgery will certainly mark him as one of the outstanding neurosurgeons of all time.