NOTTINGHAM’S EMINENT SURGEONS AND PHYSICIANS


WILLIAM SWANSON WHIMSTER


President of the Nottingham Medico-Chirurgical Society

1958 -1959


William Swanson Whimster: "Parkdale," Pevril Drive, The Park, Nottingham. M.D., London 1928, M.B., B.S., 1926; M.R.C.P., London 1929; M.R.C.S. England; L.R.C.P. London, 1925 (Guys): Physician General, Highbury and City Hospitals, Nottingham. Fellow of the Royal Society of Medicine; Member of the Nottingham Medico-Chirurgical Society. Late, Resident Medical Officer Ancoats Hospital, Manchester; House Physician Warneford Hospital, Leamington Spa; Senior House Surgeon, Royal United Hospital, Bath.


Medical Directory 1959.


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William Swanson Whimster, Born 12th May, 1902, Died 30th May, 1969. M.R.C.S., L.R.C.P. (1925) M.B., B.S. London (1926) M.D. (1928) M.R.C.P. (1929), F.R.C.P. (1960)


William Swanson Whimster was born at Wood Green in Middlesex, the elder son of William Swanson Whimster, an emigre Scot and hardware merchant, and of Catherine Whimster (nee Cameron).


He also became clinical assistant to Sir (then Dr.) Charles Symonds at the National Hospitals for Nervous Diseases, Queen Square, London, where he attended weekly until the outbreak of war.


He was medically unfit for military service and so continued his practice with the help of assistants when his partner, He was educated at the City of London School and entered Guy's Hospital in October 1919, qualifyint M.R.C.S., L.R.C.P. in 1925 and M.B., B.S. in 1926. He enjoyed his time at Guy's, taking part in the athletics and rugby, and often recalled the teaching of Sir Arthur Hurst and John Ryle. After resident appointments at the Warneford Hospital, Leamington Spa, and the United Hospitals in Bath, he took the post of medical officer on the cargo ship TSS Cachas of the Blue Funnel Line and sailed from Liverpool in August 1927 to China and Japan. In the Indian Ocean he experienced his first attack of atrial fibrillation which lasted for four days and troubled him intermittently until 1955 when it became continuous. He was always on the treatment of cardiac arrhythmia's.


In February 1928 he was appointed resident medical officer at Ancoats Hospital, Manchester. During this appointment he proceeded M.D., took the M.R.C.P., and met his wife.


In May 1930 he took over a single-handed general practice in Nottingham to which he was attracted because it was a university town, and offered opportunities for what he called a 'centre of town' physician and honorary hospital appointments. By 1931 he was clinical assistant at the Nottingham General Hospital and medical officer to the University College and to Raleigh Industries. Kenneth Minto, was called up. He became medical officer to No.1 Ordnance Field Park, Royal Canadian Ordnance Corps, which was stationed in Nottingham. In 1941 he was appointed honorary physician to Mansfield General Hospital and became senior physician and chairman of the Medical Committee there, before resigning in 1952. In 1944 he was made assistant physician to the Nottingham General Hospital and physician in 1946. From the inception of the National Health Service he held appointments as consultant to the General, City, Highbury, and Mapperley Hospitals in Nottingham, and to Saxondale Hospital, Radcliffe-on-Trent. He continued general medical practice with neurology, of which he remained the only local practitioner up to his retirement.


He was a founder member of, and for years honorary treasurer and finally president of, the East Midlands Society of Physicians. He served on the Council, and in 1958-59 was president of the Nottingham Medico-Chirurgical Society. He was member of the Nottingham No.4 Hospital Management Committee, chairman of the Highbury Hospital Medical Committee, and honorary secretary of the General Hospital Management Committee. From 1961 to 1966 he was a member of the Sheffield Regional Board. For the last 15 months before his retirement he was senior physician at the Nottingham General Hospital, and the last physician to have come to hospital consultantship through general practice.


William Whimster was a thoughtful, energetic man whose sympathetic and encouraging manner was well suited to the long-term problems of neurological patients. He developed a most satisfactory relationship with the psychiatrists (and was consultant to the local mental hospitals) and with neurosurgeons in Derby. He did not often publish but was sought after as a speaker and committee man with a strong sense of public duty. He was particularly aware of the need for hospital administration to be tempered by medical humanity

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In 1930 he married Madge Elizabeth Edwards, M.B. Ch.B. (Manchester) youngest child of Frederick Fountain Edwards of Manchester. He was fortunate to live to see his three sons married and qualified as a pathologist, a veterinary surgeon, and a consulting engineer.


He had a deep knowledge and love of the English countryside and its history, and in later years was able to travel abroad to visit his doctor son in Fiji and Jamaica, and also visited the continent and Egypt. He was an enthusiastic photographer whose colour slides enhanced his travel talks, which were in demand after his retirement. His accomplished public speaking and many tit bits of information came from his wide reading and long membership of the Rotary Club and the local Magdala Debating Society. His junior staff and his sons greatly appreciated the byways of learning, both medical and lay, into which he led them.


From the Lives of Fellows of the Royal College of Physicians.


Munks Roll, pages 456 and 457.


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PRESIDENTIAL ADDRESS


‘SOME PAINS AND PARESES OF THE ARM’


Delivered Wednesday, October 1st, 1958.


Ladies and Gentlemen,


I must begin by expressing to you my humble thanks for having elected me your President for this Session. I can but give my assurance that I will spare no effort to maintain the high traditions of our ancient society.


I calculate that I have listened to over twenty Presidential Addresses in this room, though never arranged this way round. They have ranged from professional through historical and reminiscent, to almost futurist. One of the most memorable was the first I heard. It was given by Dr. Wilkie Scott in 1930, and was a clinical talk on Congenital Hypertrophic Pyloric Stenosis. I, too, am attempting no evocation of the past, and no flight into the future. Mine is a clinical talk, on some of the pains and pareses which afflict the arm.


To compass the subject in full would be quite impossible in any reasonable time. It would involve the consideration of every structure, bone, muscle, joint, nerve and blood vessel which enters into the anatomy of the arm, whether directly or by reference. I have therefore selected certain more or less common conditions - mainly, as you no doubt expect, from the field of Neurology.


Firstly, since the basis of diagnosis in such cases must be anatomical, a word about anatomy.


Most of you will remember that the arm is supplied by a fifth, sixth, seventh and eighth cervical roots and the first thoracic. These form the Brachial Plexus which runs across the Thoracic Inlet between the clavicle and the first rib where it is associated with the subclavian artery. As the plexus passes behind the clavicle, it consists of an upper part to become the median nerve, a lower part to become the ulnar, and the posterior which becomes the radial nerve.


The charts demonstrate the dermatone supplied by each root and the area of supply of the three nerves.


On the muscular side, it will suffice, I think, to remember that the radial nerve supplies the triceps and the diriflexors of the wrist; the median, the biceps and the outer flexors of the wrist with two of the small muscles of the hand; and the ulnar supplies the inner flexors of the wrist and most of the small muscles of the hand.


So much for anatomy.


Among the very serious but very trying pains which humanity is called upon to bear, is that group of discomforts in the arm and hand called variously Branchial Neuritis, Acroparaesthesiae and many other names. Over the past ten years the origins of most of these diseases have been  elucidated.


One of the most fruitful of recent conceptions has been that of Cervical Spondylosis. It has been known for a long time that intervertebral disc degeneration and osteophytic could occur in the spinal column. Only over the past fifteen years or so has it been realised that in the cervical region could this produce marked neurological symptoms. Here, I am afraid, we must have some anatomy. As the spinal cord passes down from the foramen magnum to the thoracic region, it has anteriorly the anterior common ligament, and then vertebral bodies with their discs. The cervical nerves come off at right angles and immediately enter the intervertabral formina. If the disc degenerates, osteophytic formation will occur at any levels from C5 to T1, and in any or all of three directions. If the main protrusion is backward, the spinal cord may be impinged upon and paraplegia result. This is not, however, germane to our present argument. If the protrusion is lateral, it may obstruct the foramina, and nerve root pressure and irritation occur. vascular disturbance and oedema are important factors in the symptoms, and these fluctuations account for the variability of the symptoms in the arms. Motor and/or sensory roots may be involved and some or all of the cervical roots on either or both sides. Naturally the patients are elderly. Apart from cases following injury, or with congenital anomaly, I have seen one under fifty, and mostly they are over fifty-five. It afflicts both sexes. The pain is present day and night, and may so interfere with sleep as to cause loss of weight and severe depression. The diagnosis has to be made from local lesions in the neck and spinal cord, such as tumours of cord, vertebrae or meninges. One such which Mr. Birkett operated on recently for me certainly had spondylosis, but she also had secondary carcinoma of the meninges. Malignant glands in the neck are not uncommon, especially from bronchial neoplasma. Most rarely inflammatory lesions such as tuberculosis of a vertebra may mimic the symptoms. X-rays, careful assessment of the anatomical distribution and examination of the spinal fluid occasionally will avoid gross errors.


The second site at which arm pain originates is in the brachial plexus as it crosses between the clavicle and the first rib. The varieties of mechanism causing these symptoms are numerous. I have seen a list of fifteen anatomical variations responsible. The most obvious in the presence of a cervical rib allowing kinking of the plexus on its passage into the arm. Sometimes in these cases the subclavian may be involved and vascular insufficiency be the presenting symptom.


In the great majority, however, the lesion is not as gross as this, and I think we may leave the precise anomaly to the anatomists and concentrate on the clinical side. The vast majority of the sufferers are women. Most commonly the complaints begin following debility and fatigue, especially at the menopause. Whatever the precise anatomy, the immediate cause is the drooping sagging of the shoulder due to muscular hypotonia. Many of you will have observed the great increase in this type of complaint during the weary days of the war when the carrying of heavy shopping bags and the performance of unaccustomed work put an increased strain on the women at home. The pain in these cases is due to irritation of the lower cord of the plexus, and is felt on the ulnar side of the forearm and hand, with ‘spill-over’ to the whole arm in severe cases. The pain is largely nocturnal causing serious loss of sleep. It is eased by getting up and by various postures of the arm. It is found to be worse after heavy work, such as a wash day.


Diagnosis is fairly easy as a rule. The age is younger than the spondylotics, thirty to fifty years. X-ray may show some anomaly of the thoracic inlet. The ulnar distribution distinguishes the lesion from median nerve compression.


The third group of cases giving similar pains has been shown to be due to pressure on the median nerve in the carpal tunnel. As this slide shows, there is a gap on the volar surface between the radius and ulna through which passes the majority of the flexor tendons to the fingers, and which the only soft structure is the median nerve. Roofing over this tunnel is a tough unyielding fibrous band. If now pressure rises in the carpal tunnel, pain will be felt in the thumb, index and middle fingers supplied by the nerve. The nerve to the palm travels above the fibrous band, and is not involved. Prolonged or severe pressure will produce wasting in the abductor and opponens pollicis well shown by this slide.


As with the other two conditions, pain is largely nocturnal. It is difficult for patients to localise these pains, and ‘spill-over’ may occur and pain may be felt in the forearm, and even up to the shoulder.


Diagnosis can be difficult. Our patients are rarely trained observer and they may have to be asked to return a week later, having carefully noted the side of the pain. If this is in the median supplied fingers only, it is diagnostic. Wasting confined to the abductor pollicis is also very hopeful. Sometimes one finds an old colles fracture or a ganglion as the cause. One ganglion I saw was tuberculosis. Some of the pain in the hand in rheumatoid arthritis is thought to be of this type.


The range is wide, with a slight preponderance of women at the menopause. Either sex is affected, and not infrequently the pain affects both hands. x-ray is rarely helpful. It does give a very pretty picture of the carpal tunnel. As a rule one is forced back on one’s clinical judgement for diagnosis in the milder cases.


The diagnosis of these three types of pain in the hand and arm is of importance since though the underlying causes are not of grave significance, yet the misery produced is great, and the loss of efficiency severe. Each of the three has a treatment which is usually effective, and sometimes curative.


In the Spondylosis, a collar of newspaper may give a miraculous relief. I was asked some years ago to see a man almost suicidal with pain. He was aged about fifty-five. His X-ray showed gross spondylosis. Emergency admission to hospital and the application of a newspaper collar made him comfortable in three days. In more persistent cases we use a plastic collar.(I must note in passing that the results of this treatment in paraplegia are much less satisfactory.) After a period of rest the process seems to settle, and in the majority of cases the collar can be gradually discarded.


Operative fixation of the neck and removal of osteophyte have been tried, but are rather desperate remedies in this type of case.


The treatment of the costo-clavicular group is with shoulder-raising exercises. Bed rest is sometimes necessary. General attention to physical and mental health, and assistance in avoiding the fatigue which is usually the proximate cause, are of course, most helpful. Gradually the tendency seems to improve, and many of the cases recover in a year or two spontaneously. Operation may be necessary for cervical ribs and occasionally for other anatomical anomalies.


The carpal tunnel syndrome usually remits with rest unless there is a gross organic cause. In those cases where pain is persistent, or wasting has occurred, a simple operation for unroofing the carpal tunnel may be performed. The patient only has to stay in hospital for about four days. The results are so good that frequently patients are asking for the other side to be done as well.


I want now to pass on to discuss certain other conditions which we meet less frequently but often enough to justify mention in a review such as this.


The first is called by many names; the one I prefer is Neuralgic Amyotrophy, which indicates two main features: Pain and muscle wasting.


The history of these cases is almost stereotyped. There is fairly acute onset of pain somewhere in the shoulder girdle. It may be widespread or localised. It can be extremely severe. Examination reveals nothing, and I regret to say though I have had the opportunity of making the diagnosis at this stage in three cases, I did not do so. After a week or ten days of this pain, muscle wasting appears, not necessarily in the area which was painful. The wasting may be local to one muscle, or, as in one of my cases, so widespread that the diagnosis of myopathy was considered. As a rule the severe pain abates as the muscular weakness appears, leaving a dull ache which slowly disappears. The muscular wasting gradually recovers over a period of a year or two, in a manner suggestive of the regeneration of nerve. The only associations of this syndrome are Herpes in the brachial area, and post-serum neuritis, for example after A.T.S. It will be remarked that the story closely resembles that of poliomyelitis, and also of shingles itself, but no virus has been isolated so far. Treatment is purely expectant, but on the whole the outlook is good and one can be quite reassuring to the patient once the acutely painful state is past.


The next condition is the frozen shoulder and the shoulder hand syndrome. These can be devastating cases. They may be associated with hemiplegias, injuries, shingles and coronary thrombosis. Some seem to arise without cause. They start with pain over the deltoid insertion, which spreads over the arm and often up to the neck. The patient may or may not notice restriction of movement at the shoulder joint. In the pure frozen shoulder the pain increases and spreads for a few months till it reaches a climax then gradually recedes, leaving ultimately a fairly normal shoulder.


In the more severe shoulder hand syndrome, as the shoulder stiffens the hand begins to look smooth, the small joints stiffen in extension, the thumb becomes immobile. The whole hand and arm is very painful and useless. One has to assume some neurogenic factor in these cases, but so far no conception helpful to treatment has emerged. Particularly in cases secondary to permanent lesions such as hemiplegia the condition itself may be permanent. Pain may lessen, but use rarely returns. Local physiotherapy and cervical sympathectomy have been tried but with little success. Prevention should be attempted by passive movement of all weak or paralysed shoulders. We begin this in strokes while the patient is still unconscious. Active and resisted movements in herpes, and passive movement in cases following coronary thrombosis, may help to prevent some of these most crippling disasters.


The radial nerve comes but little into our purview now. Some of you will remember the bad old days when a man might come home drunk on a Saturday night and fall asleep with his arm over the back of his chair, and appear at the Casualty Department next morning with ‘Saturday night paralysis.’ It is a rare disease now, as is its a mimicker - lead palsy. The only cases seen are directly traumatic, and hardly concern the physician. By courtesy of Dr. O’Donovan, I show a picture of a recent case.


The last group of cases I propose to discuss are the ulnar nerve palsies. I am particularly and personally interested in these since I have a pair of very exposed ulnar nerves which I have no prospect in various ways. For instance, I cannot sit with my chin on my hand in an armchair without keeping my elbows well in to avoid pressure on the nerves. Pressure on the window ledge of my car, or even in bed may cause discomfort, numbness and not even temporary weakness. I was once asked to see a patient in a surgical ward who had pain and numbness of both ulnar nerves, due to ‘rowing’ himself up the bed with his elbows. Most of this sort of thing is trivial, easily diagnosed by the patient, and not brought to the doctor except as a passing comment. Ulnar nerve palsies are very common, and I was surprised on looking up records to find how many appeared in a year. It will be remembered that the ulnar nerve supplies nothing above the wrist crease, so that weakness in the forearm must be produced by a lesion as high as the axilla, as in the cervical rib. Wasting of the hand muscles is so commonly a result of neurological system disease such as Motor Neurone Disease, Cervical Spondylosis or tumour, that one is tempted to forget the more local causes, thus causing ‘gloom and despondency.’ If however, the wasting is unilateral, and confined to the lower ulnar distribution, a local lesion should be sought. Recently I had such a case due to osteo-arthritis at the elbow. Many others are due to unexplained ‘Neuritis’ and clear up completely.


Finally, as a curiosity, I report two cases of local pressure on the palmar branch of the ulnar nerve, giving wasting on the radial side of the hand only. Great alarm was caused in each case, with a diagnosis of that inevitably fatal condition, Motor Neurone Disease. One was a man who worked at reamering castings at ‘Rolls Royce.’ He had to grip a vibrating tool very tightly. The other was a wife of a friend of mine who decided that an overgrown privet hedge had to be cut. The recurring jolting pressure of the shears on her palm caused the trouble. When I saw her she had marked wasting of the first dorsal interosseus. Fortunately, I had seen an article on the subject, and could be reassuring, though not until recovery took place was her rather too-knowledgeable husband reassured.


SURGEONS Nottinghams Eminent Surgeons and Physicians