Walter Edward Dandy
- Arnold-Chiari malformation
- Dandy's operation
- Dandy's phenomenon
- Dandy's sign I
- Dandy's sign II
- Dandy's syndrome
- Dandy-Walker syndrome
- Dandy-Walker-like syndrome
Biography of Walter Edward Dandy
Walter Edward Dandy was a pioneer in surgery of the posterior skull cavity and intracranial vascular surgery. In 1918 he introduced ventriculography.
Dandy was born in Sedalia, Missouri, two years after his parents had migrated to the USA from Barrow-in-Furness, Lancashire, England. His father was a train driver, a socialist and a Plymouth Brethren, a Christian sect founded in Plymouth, Devon, in 1831, emphasizing the second return of Jesus.
Dandy went to the University of Missouri where he obtained a Bachelor of Arts degree in 1907 and became interested in science through the Professor of Zoology, W. C. Curtis. He was an outstanding student and a fine athlete, and was offered a Rhodes scholarship, but since at the time he could not continue medicine at Oxford, he declined and entered Johns Hopkins Medical School, where he graduated M.D. in 1910.
Whilst a student he had impressed William Stewart Halsted (1852-1922), who suggested to him that he spend his first year in the surgical Hunterian laboratory. Here he came in contact with Harvey Williams Cushing (1869-1939) and undertook his first laboratory work, which was a study of the blood supply to the pituitary. In 1911 to 1912 he was Cushing's clinical assistant, but both men possessed somewhat similar temperaments. One hospital is a too small arena for two persons, each with an ego the size of the Universe, and they had numerous clashes during this year.
Although all the other positions on the staff had been filled, the director of the hospital decided Dandy should stay, with Kenneth Daniel Blackfan (1883-1941), a resident in paediatrics, and they studied the pathogenesis of hydrocephalus and the physiology of the cerebrospinal fluid. In 1916 he was appointed Chief Resident.
In 1913, at the age of 27 years and only three years after qualification, he published a classical account of the pathogenesis and management of hydrocephalus. At the time, his mentor, Halsted, commented "Dandy will never do anything equal to this again. Few men make more than one great contribution to medicine." In fact, this was only the beginning.
Pictures of the brain
In 1917 he commenced a search for a method of localising brain tumours. Initially Dandy studied X-ray changes in 100 patients with intracranial symptoms suggestive of a new growth and showed this technique on its own to be of limited value, destruction of the sella turcia due to increased pressure being a late phenomenon. He then investigated the possibility of using radio-opaque dyes in animals and found that this gave excellent delineation, but the substances were found to be too irritating for the nervous tissue. It is said his idea of air encephalography originated when he was operating on a patient with an X-ray showing gas under the diaphragm following a perforated typhoid ulcer.
In 1918 he began x-raying patients on whom he had pumped air into the ventricular system of the brain via holes drilled in the cranium or via a fontanelle. He described the method the same year. Thus Dandy became the first to prove that CNS-structures could be mapped roentgenologically after injections of air lumbally into the subarachnoid space. Within two years after this, Bingel in Germany and Sofus Widerøe (1880-) in Norway, independently of each other and without knowledge of Dandy's work, demonstrated tumours of the spinal marrow using the same technique. Bingel called the method pneumoencephalography or encephalography.
Admired, but unpopular
Visitors from all over the world came to Dandy to see him operate. He had a reputation for being exceptionally dextrous and fast. Five patients with brain tumours came to his operating room every day. Dandy proved that it was possible to conduct intracranial surgery with an acceptable mortality, and without causing severe neurological problems in his patients postoperatively.
He was also well known for his ability to reach a correct diagnosis. There is a case that was said to have puzzled the physicians at the clinic. The patient, who had been anaesthetised, was shown to Dandy. After a short examination Dandy recommended that the man immediately should undergo a right-sided trepanation in order to drain the abscess causing the symptoms. As large quantities of matter had poured out of the trepanation hole an amazed onlooker asked how Dandy could find the diagnosis and know exactly where the trephining hole should be drilled. Dandy's answer was: "Dear colleague, God must have whispered in my ear."
Dandy collaborated little with his colleagues in neurosurgery, sticking to himself most of the time. He did not participate in discussion on the future of this neurosurgical speciality. One reason for this seems to have been the strained relationship that had developed between himself and his former teacher, Harvey Cushing. The 17-year-older Cushing was an extrovert man with broad cultural interests. Dandy was considered by many to be rather brusque, unsympathetic and categorical in his statements. Gilbert Horrax, one of Cushing's closest collaborators and a friend of Dandy, sometimes had to defend Dandy against other neurosurgeons. In a letter to a steamed up colleague he wrote: "Come, Come, face up to it. The big complaint we have against Dandy is that he is 20 years ahead of the rest of us".
In his spare time Dandy played Golf, tennis and bridge. He was also an expert on the history of the American Civil War. He had a happy home life and his son followed him into medicine.
The age of pioneers
Surgery on patients with tumours in the posterior part of the skull was a sad chapter in the early 1900s. At an international congress in London in 1913 various centres reported a mortality of 80 percent. The pioneer who reduced this figure drastically was Harvey Cushing, the greatest neurosurgeon of the era, who developed the operational techniques of intracranial surgery.
According to Cushing, the high mortality was due to several factors. One was the removing of the tumours with finger dissections under time pressure, another the lack of knowledge of the transport of liquor as well, and lack of intravenous therapy. By means of his painstaking operational methods Cushing was able to reduce mortality to 15 percent. In order not to jeopardise the life of the patients, in tumours of the angle of the pons, most commonly acusticusneurinoma, he preferred to cut through the outer capsular layer and remove the mass of the tumour, while leaving the inner capsular layer intact.
Dandy advocated a more radical surgical approach. As early as in 1925 he published the article "An operation for the total removal of cerebello-pontile (acoustic) tumors". Operating on five patients by entering the posterior of the skull suboccipitally and lifting aside the cerebellum, he was also able to extirpate the inner capsular layer without risking the patient's life. Using this technique of the posterior of the skull Dandy also operated patients with trigeminus and glossopharyngeus neuralgia.
An other field pioneered by Dandy was intracranial vascular surgery. In 1929 he operated a patient with an aneurysm of the arteria cerebri media near the point of division to arteria carotis interna.
Due to postoperative aphasia and hemiplegia Dandy was forced to reoperate the patient. Despite less than successful results Dandy's early attempts received a lot of interest. Not until in 1937 was Walsh and Love able to perform a successful carotis ligation on a patient with intracranial aneurysm. The same year Dandy successfully operated a patient with an aneurysm on the right carotis interna that had caused oculomotor paresis. During this operation he was the first in the world to apply a silver clip to the base of the aneurysm, which he subsequently burned with diathermy.
Prosper Méniére in 1861 described a number of patients with sudden attacks of vertigo, tinnitus, and progressivee deafness (Ménière's syndrome) and foresaw that the cause of the condition should be searched for in the inner ear. 13 years later Jean Martin Charcot (1825-1893) suggested that the condition could be treated by severing the eight cranial nerve. Some such operations were also conducted by, among others, Parry, in the early 1900s.
However, it was not until 1924 that Dandy resumed destructive surgical treatment in a Menière condition with crippling vertigo. The operation was performed via a small opening behind the cell system of the ear. As the method included severing of the acoustic nerve, what little was left of hearing was sacrificed. After McKenzie in 1931 had performed selective surgical treatment severing only the vestibular part of the eight cranial nerve, Dandy took up this "physiological" approach.
On some patients with double-sided Menière's syndrome, Dandy performed his operation on both sides. These patients afterwards complained of a persistent syndrome, described by Dandy in an article on Menière surgery. After Dandy's description this is called Dandy's phenomenon.