Authors: Antonia Callas
If it’s true that neurosurgeons are in love with their history, it is also true that they hold a particular passion for the legacy of Walter E. Dandy. A neurosurgical pioneer, he helped shape the foundation of neurosurgery in the first half of the 20th century. He remains relevant today because of the weight and impact of his exceptional contributions in the field.
Dorcas Hager Paget
What is perhaps lesser known is that Dr. Dandy had a significant talent for anatomy and drawing. It was first noticed by his anatomy professor at Johns Hopkins University, Dr. Franklin P. Mall, who encouraged Dandy to reconstruct and describe a very early human embryo. This led to his first article, published in 1911, accompanied by a black-and-white drawing of an embryo (Figure 1).
Figure 1: Dandy Embryo (1911) showing the yolk sac. Drawing by Walter Dandy, MD.
During Dr. Dandy’s medical school years, he also had the benefit of instruction of one of the world’s foremost medical illustrators, Max Br?del, director and founder of the department of Art as Applied to Medicine at Johns Hopkins University. Br?del coached Dandy as he began illustrations of the nerve supply and blood supply of the pituitary (Figure 2). Another striking testament to Dandy’s talent is given by Donlin Long, MD, who attended the University of Missouri Medical School in the 1950s. (Dandy had attended before transferring to Johns Hopkins.) Donlin states, “We were shown pathology drawings made by Dr. Dandy as a second year student as examples of what we should do in the same class. I later encountered the majority of the drawings at Johns Hopkins. Dr. Dandy was a remarkable medical artist, and these drawings demonstrate that talent.”1
Figure 2: Blood Supply of the Pituitary Body (1910-1911) by Walter Dandy, MD.
By 1928, Dandy’s career had progressed to the point where he needed an illustrator. Dorcas Hager Paget, born 1906, was the oldest of three sisters raised in Albany, New York. During high school, Hager Paget showed great interest in biology and illustrated a botany textbook with teacher Ada Wadler. She received a grant to attend Vassar College and was accepted into its honors program, which allowed her to attend laboratory courses.
Professor Treadwell at Vassar admired Hager Padget’s illustrations and decided to introduce her to the Art as Applied to Medicine department at Johns Hopkins. In the early summer of 1926, Hager Padget wrote to Max Br?del suggesting that she would leave Vassar one year early to take a course in medical illustration. Br?del wrote her back saying she should finish her degree and apply. Hager Padget responded in August, sending along drawings she had done in the laboratory. Br?del reconsidered her application. He knew that Dandy was in need of an illustrator. Br?del said that if Hager Padget qualified for the position, she would be allowed to work on a stipend at the end of her first year, and possibly assume a full-time position after graduation. Hager Padget left Vassar without graduating.2
“The exceptional pupil of this Group is Miss Hager. She is a Vassar girl and very gifted both in science and art,” wrote Br?del in his 1926-27 annual report to the Johns Hopkins University President. Her illustrations from this time expose her genius for rendering technique, design, and storytelling. She was evidently learning a tremendous amount about neuropathology and neuroanatomy. Like many illustrators of that era, she worked mostly in the operating room, standing behind Dr. Dandy while he performed surgery. She made many quick sketches and took notes regarding the case then used them to create a refined illustration. Many of these illustrations were used in Dandy’s book Surgery of the Brain. She became one of the leading medical illustrators in the country.3
Dandy’s book The Brain, an updated and reprinted version of Surgery of the Brain, is filled with illustrations that demonstrate a thorough understanding of anatomy, a sensitivity with the medium, and a deftness of storytelling. Hager Padget’s illustrations produce an almost instantaneous understanding of the procedure, while also allowing dense details to slowly wash over the viewer. Hager Padget employs three components that make her pieces exceptionally successful: didactic quality, exquisite rendering, and elegant design.
The first illustration of the surgical treatment of a ruptured internal carotid artery aneurysm (Figure 3), stands out for its exceptional didactic qualities. Three standard views of the patient are given for orientation. The two smaller views from the side and from above give enough information to orient the viewer to the third, larger view. The heads and brains are perfectly aligned, showing the craniotomy and a dashed line where the coronal section occurs. We also see the patient’s sex and age in text directly adjacent to the smaller heads. This technique of weaving text into the illustration was a hallmark of Hager Padget’s illustrations. This illustration encapsulates Hager Padget’s ability to take a very complex subject and break it down into teachable moments.
Figure 3: Aneurysm Internal Carotid Artery from The Brain (1969) by Walter Dandy, MD.Illustrated by Dorcas Hager Padget.
Hager Padget’s rendering ability was exceptional. This illustration (Figure 4) shows an enormous hypophysial duct cyst which extends up into the frontal lobe. It displays her thoughtful design and didactic talents by showing not only a coronal and sagittal section, but also the positioning of the head with incision, craniotomy, and the surgeon’s view during the procedure. But the focus of the piece is the beautifully rendered cyst. The light reflects and refracts as it passes through, describing its texture, viscosity and opacity. The image on the left shows the cyst and brain cut sagittally. It interweaves precise but loose pen and ink strokes with detailed tone renderings. From a distance the architecture of lines form the muscles, skin, fat, bone, and brain with precision and detail; but if you look closely, you can see how loose the pen work becomes. These marks are unique and show the hand of the artist.
Figure 4: Enormous Hypophysial Cyst from The Brain (1969) by Walter Dandy, MD. Illustrated by Dorcas Hager Padget.
Great design in illustration takes careful thought and planning. This illustration (Figure 5) describes the removal of an ependymal tumor from the right lateral ventricle. It has a beautiful, quiet, and elegant design. Starting at the upper left corner, our eyes make a full clockwise circle. Hager Padget uses hashed lines to indicate the region of the brain to be removed. Dashed lines along with the craniotomy and skin flap move our eyes to the right where we see the tumor and brain removal in overlay. We move down to that figure’s face, through the chin and into the glove of the surgeon. As we sweep by the tumor and brain, we flow through the gentle fade of the patient’s face back to our starting point. Using size, contrast, and level of detail the illustration establishes a hierarchy of importance, as well as an order of understanding.
Figure 5: Extirpation of an Ependymal Tumor of the Lateral Ventricle, from The Brain (1969) by Walter Dandy, MD. Illustrated by Dorcas Hager Padget.
Hager Padget worked at Hopkins for 22 years in the same desk she had used as a student. Over time, she became more interested in research. After Walter Dandy’s death in 1946, Hager Padget shifted gears and began to work for the Carnegie Institution of Washington in Baltimore. It was here that she did some of her most research-intensive and well-known work. She was tasked with describing the fetal arterial development by tracking the vessels through 22 separate embryos, ranging from three and a half to seven weeks. The monograph for arterial development was published in 1948 and was a significant step in the field of neuroembryology.
In 1952, Dr. James G. Arnold, Jr. at the University of Maryland School of Medicine Division of Neurological Surgery hired Hager Padget as a “research assistant”—a title she chose for its ambiguity. She wanted to shake off the idea that she was simply an artist. But her lack of credentials caused difficulties. Despite barriers, she published articles on nervous system and neural tube malformations, including one that challenged the idea that spina bifida was solely caused by incomplete neural tube closure. In her research of the Arnold-Chiari and Dandy-Walker syndromes, she coined the term “neuroschisis,” which described abnormal clefts in the neural tube. She authored numerous papers on congenital malformations of the nervous system, and was a pioneer in visualizing the complex development of embryological vasculature.
Hager Padget had struggled with cancer beginning in the early 1950s. Despite health problems, she continued her research until September 15, 1973, when she passed away at the Johns Hopkins Hospital. Dorcas Hager Padget illustrations remain masterful works of art: thoughtful, precise, and exquisitely rendered. Her transition from illustrator to scientist was accomplished in an era where women met resistance entering the male-dominated fields of science and medicine. More amazingly, she accomplished all of this without a bachelors or graduate degree. She set the standard for neurosurgical illustration and her effect on the fields of neurosurgical illustration and neuroembryology are still felt today.
To read the full, unedited article A Scientist Renders by Jared Travnicek, visit fortnightjournal.com. Jared Travnicek is a medical illustrator based in Indianapolis, Indiana. To see his illustrations, visit jtsciencevisuals.com.
Figures 3-5: Original illustrations from the Dandy/Padget collection of the Max Br?del Archives, in the Department of Art as Applied to Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.