ds to the stratum corneum--raising it from its
bed.

There is some local heat and discoloration, and considerable pain and
tenderness, but little or no constitutional disturbance. Superficial
lymphangitis may extend a short distance up the forearm. By clipping
away the raised epidermis, and if necessary the nail, the pus is allowed
to escape, and healing speedily takes place.

_Whitlow at the Nail Fold._--This variety, which is met with among those
who handle septic material, occurs in the sulcus between the nail and
the skin, and is due to the introduction of infective matter at the root
of the nail (Fig. 9, b). A small focus of suppuration forms under the
nail, with swelling and redness of the nail fold, causing intense pain
and discomfort, interfering with sleep, and producing a constitutional
reaction out of all proportion to the local lesion.

To allow the pus to escape, it is necessary, under local anaesthesia, to
cut away the nail fold as well as the portion of nail in the infected
area, or, it may be, to remove the nail entirely. If only a small
opening is made in the nail it is apt to be blocked by granulations.

[Illustration: FIG. 9.--Diagram of various forms of Whitlow.
a = Purulent blister.
b = Suppuration at nail fold.
c = Subcutaneous whitlow.
d = Whitlow in sheath of flexor tendon (e). ]

_Subcutaneous Whitlow._--In this variety the infection manifests itself
as a cellulitis of the pulp of the finger (Fig. 9, c), which sometimes
spreads towards the palm of the hand. The finger becomes red, swollen,
and tense; there is severe throbbing pain, which is usually worst at
night and prevents sleep, and the part is extremely tender on pressure.
When the palm is invaded there may be marked oedema of the back of the
hand, the dense integument of the palm preventing the swelling from
appearing on the front. The pus may be under such tension that
fluctuation cannot be detected. The patient is usually able to flex the
finger to a certain extent without increasing the pain--a point which
indicates that the tendon sheaths have not been invaded. The
suppurative process may, however, spread to the tendon sheaths, or even
to the bone. Sometimes the excessive tension and virulent toxins induce
actual gangrene of the distal part, or even of the whole finger. There
is considerable constitutional disturbance, the temperature often
reaching 101 or 102 F.

The treatment consists in applying a constriction band a