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The Practitioner

The Practitioner contributes to the formal clinical literature and is primarily aimed at GPs, with subscribers throughout the world. All articles in The Practitioner online include CPD frameworks for personal reflection on learning and drafting of plans that will have an impact on practice. Preset search links to PubMed and NICE Evidence are associated with most major articles.

 

Symposium articles

GPs should be vigilant for Parkinson’s disease

25 Sep 2021Registered users

Parkinson's disease is the second most common neurodegenerative disease. Parkinsonism is defined as bradykinesia in combination with at least one of rest tremor or rigidity. Parkinson's disease is a clinical diagnosis. Examination should include gait and posture, decreased blink rate and a lack of spontaneous facial movements. Speech will be hypophonic. Evidence of a resting tremor should be sought and the patient assessed for joint rigidity and bradykinesia. After initial assessment, prompt referral to a neurologist is important to confirm the diagnosis and discuss management.

History and examination pivotal in diagnosis of Bell’s palsy

24 Sep 2021Registered users

Bell’s palsy is the most common cause of facial palsy and presents as a unilateral lower motor neurone facial weakness in association with sensory and parasympathetic dysfunction. Maximal facial weakness occurs within 72 hours and most cases recover over the following few weeks. It is essential to consider alternative causes of acute peripheral facial palsy including: infection, malignancy and autoimmune disease. Urgent referral to neurology or ENT, depending on local referral pathways, is warranted if there is uncertainty about the diagnosis or there are atypical features.

Multidisciplinary care is key in chronic pancreatitis

26 Jul 2021Paid-up subscribers

In chronic pancreatitis chronic inflammation of the pancreas results in irreversible injury and fibrosis. The most common causal factor is excess alcohol consumption. Smoking is an independent risk factor. Gene mutations can lead to hereditary chronic pancreatitis and idiopathic disease, where no clear cause can be identified, accounts for 20-30% of cases. The typical presenting symptom is intermittent or continuous upper abdominal pain which may radiate to the back. The pain is commonly triggered or exacerbated by eating or alcohol consumption.

Prevention, diagnosis and treatment of colorectal cancer

26 Jul 2021

Colorectal cancer is the third most common cancer in both women and men and is the second most common cause of cancer death in the UK. The main symptoms patients with colorectal cancer present with are: persistent blood in faeces; persistent change in bowel habit and persistent lower abdominal pain. Less obvious presentations are unexplained weight loss, tiredness for no reason, general malaise and iron deficiency anaemia found on blood testing.

 

Special reports

Early detection of cutaneous melanoma improves prognosis

24 Sep 2021

Exposure to intermittent intense sunlight and sunburn (especially in childhood) are the most common modifiable risk factors for melanoma. Individuals with lighter skin tones are at greatest risk (Fitzpatrick skin types I-II). A history of melanoma increases the risk of a further melanoma eight-fold. Approximately 5-10% of melanoma cases are estimated to be familial. The 7-point checklist is recommended by NICE to help determine when a referral is indicated. However, checklists should not be used in isolation as some melanomas will be missed. Amelanotic melanomas, estimated at 10% of all melanomas, remain a challenge. 

Early recognition of hyperemesis gravidarum can prevent complications

26 Jul 2021Registered users

Nausea and vomiting in pregnancy is very common and affects up to 80% of women. It is usually mild and resolves during the first half of pregnancy. However, in a small proportion of women (0.3–3.6%), symptoms are so severe that they lead to dehydration, electrolyte imbalance and weight loss. This is known as hyperemesis gravidarum. Women who have persistent symptoms into the second trimester of pregnancy should have consultant-led antenatal care and serial fetal growth ultrasound.

Improving the detection of cutaneous squamous cell carcinoma

25 Jun 2021

Cutaneous squamous cell carcinoma (cSCC) can develop de novo or from pre-existing chronic actinic damage, although the probability and speed of transition from actinic keratosis to cSCC is highly variable. The occurrence of cSCC is related to chronic UV exposure, particularly occupational exposure. Risk factors include fairer skin, significant exposure to sunlight or PUVA. Incidence is also significantly increased in patients who are immunosuppressed. All patients with suspected cSCC should be referred via the two-week wait pathway to dermatology.

Diagnosis and management of primary hyperparathyroidism

25 May 2021Registered users

Primary hyperparathyroidism (PHPT) most commonly occurs sporadically, typically caused by a parathyroid adenoma. Such cases are more common in women and with increasing age. Other risk factors include neck irradiation and lithium use. Inherited cases can occur in relation to genetic conditions including MEN1. Parathyroid carcinoma is vanishingly rare. PHPT may present with symptoms of hypercalcaemia (such as thirst, excessive urination or constipation), or evidence of potential end organ effects. However, the most common presentation is an incidental finding of a raised albumin-adjusted serum calcium.

 

Women's health

GPs have a key role in the management of miscarriage

22 Mar 2021Registered users

First trimester miscarriage affects up to one in four pregnancies. While some women will experience bleeding and pain, others have no symptoms and are given the diagnosis at their 12-13 week booking scan. In 50-85% of cases the cause is due to a spontaneous chromosomal abnormality, most commonly trisomy. Many women suffer from psychological sequelae including PTSD, anxiety and depression. GPs should offer a follow-up appointment to all women who have had a miscarriage to: discuss any questions the woman has regarding her miscarriage; assess the woman’s psychological wellbeing and offer counselling if appropriate.

Have a high index of suspicion for ectopic pregnancy

24 Mar 2020Registered users

Ectopic pregnancy is estimated to occur in 1-2% of all pregnancies and continues to be the leading cause of maternal mortality in early pregnancy. Most ectopic pregnancies are located within the fallopian tube and carry a risk of tubal rupture and intra-abdominal bleeding. Women with ectopic pregnancy can present in a wide variety of ways, from acute collapse following rupture to asymptomatic and unaware that they are pregnant. Symptoms may include vaginal bleeding and abdominal pain. There may also be non-specific symptoms such as Gl and urinary symptoms, rectal pressure, dizziness, shoulder tip pain, fainting or syncope. 

Investigating the cause of heavy menstrual bleeding

25 Mar 2019Registered users

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

Symptom recognition key to diagnosing endometriosis

22 Mar 2018Registered users

Endometriosis affects around one in ten women of reproductive age in the UK. NICE guidance highlights the importance of symptoms in its diagnosis. A normal abdominal or pelvic examination, ultrasound, or MRI should not exclude the diagnosis. Endometriosis should be suspected in women and adolescents who present with one or more of: chronic pelvic pain, significant dysmenorrhoea, deep dyspareunia, period-related or cyclical GI or urinary symptoms, or infertility. If endometriosis is suspected or symptoms persist, patients should be referred for further assessment.

 

Care of the elderly

Diagnosis and management of age-related macular degeneration

25 Jan 2021Paid-up subscribers

Age-related macular degeneration (AMD) is a cause of painless, gradual loss of vision. Epidemiological evidence suggests 4-8% of people aged over 65 years in the UK have visually significant AMD. Patients with suspected neovascular AMD (NvAMD) should be seen by ophthalmology within two weeks, and if the diagnosis and progressive disease are confirmed, treatment should commence within the same timeframe. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents cause regression of neovascularisation and reduce macular oedema. There is no treatment for dry AMD.

Diagnosing anxiety disorders in older adults can be challenging

25 Jan 2021Paid-up subscribers

In older adults, the prevalence of anxiety disorders is higher among those with other health problems, and those in hospital and care settings. A primary depressive disorder should be excluded whenever an older person presents with anxiety symptoms for the first time, and comorbid anxiety often indicates a more severe presentation of depression. Around four in five patients have a comorbid physical disorder. Medical conditions can mimic symptoms of, predispose to, or even directly precipitate an anxiety disorder, and may colour its symptomatology or limit treatment options.

Elderly onset RA: a diagnostic and therapeutic challenge

23 Jan 2020Paid-up subscribers

Elderly onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) with age of first onset 65 years or over. It comprises an acute onset proximal or large joint arthritis with a prominent systemic syndrome characterised by constitutional symptoms and a higher ESR than in the younger patient with RA. Investigations should focus on trying to establish the cause and ruling out differential diagnoses. They should include inflammatory markers, serum uric acid, full blood count, rheumatoid factor/anti-CCP antibodies, and X-rays of the affected joint as well as the hands and feet. The possibility of malignancy should always be borne in mind. NICE recommends urgent referral of all suspected cases.

 

Musculoskeletal medicine

Treating to target will optimise long-term outcomes in RA

24 Nov 2020Paid-up subscribers

Rheumatoid arthritis (RA) classically causes a symmetrical, small joint polyarthritis which left untreated can lead to joint destruction and deformity. NICE recommends that any adult with suspected persistent synovitis of undetermined cause should be referred for a specialist opinion. Patients should be referred urgently (even with a normal acute-phase response, negative anti-CCP antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected; > 1 joint is affected; there has been a delay of ≥ 3 months between onset of symptoms and seeking medical advice.

Diagnosis and management of Paget’s disease of bone

24 Nov 2020

Paget’s disease of bone is a metabolic disease in which focal abnormalities of bone remodelling occur in one or more skeletal sites. The affected bones enlarge and may become deformed and this can lead to complications including bone pain, pathological fractures, secondary osteoarthritis, deafness and nerve compression syndromes. The three main risk factors are age, male gender and family history. People with a first-degree relative with Paget’s disease have a seven-fold increased risk of developing the disease. Patients who have bone deformity or symptoms that might be due to Paget’s disease should be referred to secondary care. 

 

Gastroenterology

Early treatment can arrest or reverse cirrhosis

24 Jul 2020Paid-up subscribers

Around 60,000 people in the UK are estimated to have cirrhosis. It is now the third most common cause of premature death. Decompensation represents a watershed moment for patients with cirrhosis, with the median survival falling from > 12 years for compensated cirrhosis to approximately two years. Patients with cirrhosis should undergo six-monthly ultrasound to screen for the early development of primary hepatocellular carcinoma. They should also undergo an initial upper gastrointestinal endoscopy to screen for varices.

Tailor treatment to the patient with gallstone disease

24 Jul 2020Paid-up subscribers

Gallstones affect around 15% of adults in the UK. Between 50 and 70% of patients with gallstones are asymptomatic at diagnosis and only 10-25% of these individuals will go on to develop symptomatic gallstone disease. The vast majority (90-95%) of gallstones are cholesterol stones. Obesity is associated with an increased risk of symptomatic gallstones. Patients with symptoms suggestive of gallstones should be offered liver function tests and an abdominal ultrasound.

 

Psychiatry

Early recognition key in child and adolescent anxiety disorders

23 Apr 2020Registered users

Anxiety disorders are common, highly treatable conditions, with a strong evidence base for cognitive behaviour therapy. In a recent population sample of the under 12s, only 65% of those who met criteria for a diagnosis of an anxiety disorder had sought professional help and only 3.4% had received an evidence-based treatment. Assessment should include an exploration of neurodevelopmental conditions, drug and alcohol misuse, and speech and language problems.

Treating psychological trauma in the real world

23 Jan 2020Paid-up subscribers

After a potentially traumatic event (PTE), many individuals experience either no distress or only transient distress, while others suffer considerable morbidity and may develop post-traumatic stress disorder (PTSD). Around one-third of people experiencing a PTE will develop PTSD, though this varies depending on the type of traumatic event and rates of PTSD are higher with type 2 trauma. Type 2 trauma involves repeated traumatic experiences over extended periods. Although PTSD symptoms can be present acutely, the diagnosis requires the persistence of symptoms for at least one month and the symptoms should cause functional impairment.

Early intervention key in first episode psychosis

20 Dec 2019Paid-up subscribers

Psychosis is a state of mind in which a person loses contact with reality in at least one important respect while not intoxicated with, or withdrawing from, alcohol or drugs, and while not affected by an acute physical illness that better accounts for the symptoms. Common positive symptoms of psychosis include delusions and hallucinations. These symptoms are strongly influenced by the underlying cause of the psychosis: delusions in schizophrenia tend to be bizarre; delusions in depression negative; delusions in mania expansive. When a patient presents with psychotic symptoms, it is important to take a full psychiatric history, perform a mental state examination and complete relevant investigations, as indicated in each individual case.

 

Neurology

Detailed history the cornerstone of epilepsy diagnosis

24 Sep 2020

The incidence of epilepsy in the UK is estimated to be 50 per 100,000 per year and up to 1% of the population have active epilepsy. The diagnosis of epilepsy will usually be made in a neurology clinic. A generalised seizure as part of a generalised epilepsy syndrome may occur without warning but may be preceded by blank spells or myoclonic jerks. A generalised seizure with focal onset may be preceded by an aura. Brain imaging is required in almost all cases where epilepsy is suspected, the only possible exception being people with generalised epilepsies proven on EEG. MRI is the imaging modality of choice.

GPs should be vigilant for acute deterioration in myasthenia gravis

24 Sep 2020Registered users

Myasthenia gravis is an autoimmune disorder of neuromuscular junction transmission. It is relatively rare, with an approximate annual incidence of 1 per 100,000 population, and prevalence of 15 per 100,000 population in the UK. An ocular presentation may include fatiguing ptosis or diplopia. Typically, symptoms ‘fatigue’ (the physical power of the muscle deteriorates rapidly with repeated activity) and become more noticeable as the day progresses. More generalised symptoms include fatiguing difficulty with speech or swallowing. There may be fatiguing weakness of the arms and legs. The diagnosis will usually be confirmed by referral to a neurologist. 

 

CPD exercises associated with each issue

CPD exercise - September 2021

24 Sep 2021Paid-up subscribers

All articles in The Practitioner online are associated with fillable PDF frameworks for personal reflection on learning and drafting of plans for CPD. These templates are also included here in our standard study pack containing this month’s CPD exercise plus all relevant articles: • GPs should be vigilant for Parkinson's disease • History and examination pivotal in diagnosis of Bell's palsy • Early detection of cutaneous melanoma improves prognosis

CPD exercise - July/August 2021

26 Jul 2021Paid-up subscribers

All articles in The Practitioner online are associated with fillable PDF frameworks for personal reflection on learning and drafting of plans for CPD. These templates are also included here in our standard study pack containing this month’s CPD exercise plus all relevant articles: • Multidisciplinary care is key in chronic pancreatitis • Prevention, diagnosis and treatment of colorectal cancer • Early recognition of hyperemesis gravidarum

CPD exercise - June 2021

25 Jun 2021Paid-up subscribers

All articles in The Practitioner online are associated with fillable PDF frameworks for personal reflection on learning and drafting of plans for CPD. These templates are also included here in our standard study pack containing this month’s CPD exercise plus all relevant articles: • Juvenile spondyloarthropathies often go unrecognised • Diagnosis and management of acute asthma in children • Improving the detection of cutaneous squamous cell carcinoma

 

A hundred years ago

100 years ago: Pleurisy: the doctor’s dilemma

24 Sep 2021Registered users

A doctor’s wife had fluid in her chest. She was seen by another doctor in the same town, who aspirated her chest and did not notice whether the fluid contained albumen. Fearing that it was a tuberculous case, he sent her away for six months. She was not benefited. She passed through London on her way back – and I was asked to see her. I put a needle into the chest and aspirated fluid containing no albumen. She was operated on, and hydatids were evacuated from the chest. Unfortunately, just after the operation, a yellow fog set in over London, lasting three or four days, and that killed her. Nevertheless, if we had known six months earlier that the fluid was hydatid, and not tuberculous, it is quite likely that the woman’s life would have been saved.

 

Editorials

Cognitive stimulation at work may reduce dementia risk

24 Sep 2021Registered users

People who work in cognitively stimulating jobs are at lower risk of dementia than those who work in non-stimulating jobs, a large multicohort study has found.

Discontinuing rivaroxaban affects outcomes in atherosclerotic disease

26 Jul 2021Registered users

The combination of rivaroxaban and aspirin compared with aspirin alone significantly reduced cardiovascular outcomes in patients with chronic coronary artery disease or peripheral artery disease, a large study has shown. However, when rivaroxaban therapy was discontinued at the end of the trial the benefits were lost and a higher stroke rate was seen in those originally randomised to combination therapy.

 

Research reviews - by GPs with a special interest

Rehabilitation improves physical function in older heart failure patients

25 Sep 2021Registered users

In older patients hospitalised for acute decompensated heart failure an early tailored rehabilitation programme resulted in a greater improvement in physical function compared with usual care together with a reduction in falls and improvement in mood. However, the programme did not result in a significant reduction in readmissions or deaths.

Simple algorithm helps identify patients with NAFLD in primary care

24 Sep 2021Registered users

Using a multistep algorithm based on risk factors and noninvasive testing followed by targeted transient elastography can identify patients with non-alcoholic fatty liver disease (NAFLD) in primary care, a study from the United States has found.

Asthma admissions in under 5s fall following smoking ban in vehicles

24 Sep 2021Registered users

Hospitalisation rates for asthma in preschool children have significantly declined since the ban on smoking in vehicles carrying children in Scotland, a study has found.

Evaluating interventions to help smokers quit

09 Aug 2021Registered users

Varenicline and a combination of pharmacological and behavioural interventions were the two most effective methods for smoking cessation, a systematic review by the US Preventive Services Task Force has found. Data on the effectiveness and safety of e-cigarettes for smoking cessation in adults were limited and study results inconsistent.

 

HASLAM's view

Haslam’s view: If in doubt ‘just check with your GP’

24 Sep 2021Registered users

My personal agony uncle experience has always made me somewhat sceptical about other Q & A columns in magazines, although they can sometimes be a source of rather random knowledge. Nevertheless, there is one phrase that gets used repeatedly, and still really irritates me – the answer that closes with the words, ‘if you are in any doubt, just check with your GP.’

 

Cancer - Temporary direct access

Early detection of cutaneous melanoma improves prognosis

24 Sep 2021

Exposure to intermittent intense sunlight and sunburn (especially in childhood) are the most common modifiable risk factors for melanoma. Individuals with lighter skin tones are at greatest risk (Fitzpatrick skin types I-II). A history of melanoma increases the risk of a further melanoma eight-fold. Approximately 5-10% of melanoma cases are estimated to be familial. The 7-point checklist is recommended by NICE to help determine when a referral is indicated. However, checklists should not be used in isolation as some melanomas will be missed. Amelanotic melanomas, estimated at 10% of all melanomas, remain a challenge. 

Prevention, diagnosis and treatment of colorectal cancer

26 Jul 2021

Colorectal cancer is the third most common cancer in both women and men and is the second most common cause of cancer death in the UK. The main symptoms patients with colorectal cancer present with are: persistent blood in faeces; persistent change in bowel habit and persistent lower abdominal pain. Less obvious presentations are unexplained weight loss, tiredness for no reason, general malaise and iron deficiency anaemia found on blood testing.

Improving the detection of cutaneous squamous cell carcinoma

25 Jun 2021

Cutaneous squamous cell carcinoma (cSCC) can develop de novo or from pre-existing chronic actinic damage, although the probability and speed of transition from actinic keratosis to cSCC is highly variable. The occurrence of cSCC is related to chronic UV exposure, particularly occupational exposure. Risk factors include fairer skin, significant exposure to sunlight or PUVA. Incidence is also significantly increased in patients who are immunosuppressed. All patients with suspected cSCC should be referred via the two-week wait pathway to dermatology.

GPs should have a high index of suspicion for testicular cancer

22 Apr 2021

Most men with testicular cancer present with a lump that they have identified in their scrotum. Although the scrotal swelling is usually painless, pain is the first symptom in around 20% of patients, typically a dull or dragging ache in the testicle or a heaviness in the scrotum. NICE recommends that all men who have a non-painful enlargement or change in shape or texture of their testis should be referred urgently to urology using the two-week wait pathway. In men who have unexplained or persistent testicular symptoms, an urgent direct access testicular ultrasound scan should be requested. 

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease. 

Optimising the management of early prostate cancer

23 Apr 2020

Men born after 1960 in the UK now have a 1 in 6 estimated lifetime risk of being diagnosed with prostate cancer. NICE recommends that men over 50 years old who request a PSA test should be fully counselled about the test beforehand. The test should also be offered to men with LUTS or an abnormal DRE. If the prostate feels malignant on DRE this should trigger a fast track referral to secondary care, via a suspected cancer pathway referral, even if the PSA is normal. Men with PSA values above the age-specific reference range should also be referred to urology urgently, via a suspected cancer pathway referral.

Time to diagnosis key in improving lung cancer outcomes

25 Nov 2019

NICE recommends urgent referral via a suspected cancer referral pathway to the two week wait service if: chest X-ray findings suggest lung cancer or if patients aged 40 and over have unexplained haemoptysis. However, studies have indicated that around 20-25% of patients with confirmed lung cancer may have a chest X-ray reported as normal and this figure may be higher for early stage lung cancers. Therefore, the National Optimal Lung Cancer Pathway recommends that where there is a high suspicion of underlying malignancy (but the chest X-ray is normal), GPs should refer patients directly for a CT scan.

Early detection of liver cancer key to improving outcomes

07 Aug 2019

Hepatocellular carcinoma (HCC) accounts for around 90% of liver cancer cases and intrahepatic cholangiocarcinoma (CC) for 9-10%. Most cases of HCC occur in the context of chronic liver disease with cirrhosis, particularly in those with chronic hepatitis B or C. Other major risk factors include excessive alcohol consumption, obesity and aflatoxins. Overall, 10-15% of cirrhotic patients will develop HCC within 20 years. Patients presenting with an upper abdominal mass consistent with an enlarged liver should be referred for an urgent direct access ultrasound scan within two weeks. 

Improving outcomes in pancreatic cancer

25 Jul 2018

The combination of an aggressive disease, vague presenting symptoms and insensitive standard diagnostic tests is a key factor contributing to poor outcomes with only 15% of patients with pancreatic cancer having operable disease at diagnosis. The NICE guideline on referral for suspected cancer recommends urgent referral via a suspected cancer pathway referral if the patient is aged 40 and over with jaundice. It also recommends that an urgent direct access computerised tomography (CT) scan referral should be considered in patients aged 60 and over with weight loss and any of the following: diarrhoea; back pain; abdominal pain; nausea; vomiting; constipation; new onset diabetes. Pancreatic cancer requires a CT scan for diagnosis.

Diagnosis and management of oesophageal cancer

22 Feb 2018

Oesophageal cancer commonly presents with dysphagia or odynophagia and can be associated with weight loss and vomiting. Referral for urgent endoscopy should always be considered in the presence of dysphagia regardless of previous history or medication. NICE recommends urgent referral (within 2 weeks) for direct access for upper GI endoscopy in patients with dysphagia and those aged 55 years or over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

Prompt investigation improves outcomes for kidney cancer

22 Feb 2018

Renal cell carcinoma should be suspected in the presence of: localising symptoms such as flank pain, a loin mass or haematuria; constitutional upset including weight loss, pyrexia and/or night sweats; or unexplained test results. Smoking, obesity and hypertension are common risk factors and all three demonstrate a dose-response relationship with the relative risk of renal cell carcinoma.

 

A hundred and fifty years ago

A 150 years ago: How not to treat chronic rheumatoid arthritis

24 Sep 2021Registered users

I cannot too strongly protest against the therapeutic doctrine of ‘rest’ being so caricatured as to imprison a joint in splints for weeks or months at a time; the last hope of rescuing it from permanent uselessness may thus be destroyed. Intercurrent attacks of inflammation may peremptorily require a joint to be rested; to be placed for a few days on a back splint, to be poulticed, or even mildly blistered; but this is quite a different thing from putting it, whether inflamed or not, into a splint-case or box, and condemning it to a chronic fixed position.