PITYRIASIS MACULATA ET CIROINATA. 
BY 
LOUIS A. DUHRING, M.D., 
PROCESSOR or SKIN DISEASES IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA; 
DERMATOLOGIST TO THE PHILADELPHIA HOSPITAL,- AND CONSULTING PHYSICIAN 
TO THE DISPENSARY FOR SKIN DISEASES, PHILADELPHIA. 
Extracted from the American Journal of the Medical Sciences for October, 1880 
COLLINS, PRINTER. [Extracted from the American Journal of the Medical Sciences for October, 1880.] 
PITYRIASIS MACULATA ET CIRCINATA.1 
LOUIS A. DUHEING, M.D., 
PROFESSOR OP SKIN DISEASES IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA; 
DERMATOLOGIST TO THE PHILADELPHIA HOSPITAL ; AND CONSULTING PHYSICIAN 
TO THE DISPENSARY FOR SKIN DISEASES, PHILADELPHIA. 
In the present communication I shall notice a disease of some impor- 
tance, and also of rarity, examples of which have from time to time been 
seen by me. It is a disease of considerable importance, for the reason 
that it may occupy a large area of skin, and consequently occasion 
alarm to the patient; and, secondly, because it is liable to be confounded 
with other well-known affections to which it bears close resemblance. It 
is, moreover, a rare disease, only ten cases having in as many years come 
to my notice, and by far the greater number of these have been observed 
within the past two years. As I shall point out later, the disease, although 
unknown in Germany, England, and this country, finding no place in the 
literature of these countries, has nevertheless been described in France, 
but it is only very recently that my attention has been directed to this 
information. The notes of the cases which I am about to give were 
made, of course, independent of the articles referred to, and with the idea 
at the time that the affection had not as yet been described. They were, 
moreover, taken in each case at the time of the observation, as is my cus- 
tom in all cases of unusual interest or of rarity. 
The first case of which I have any record is that of a working man who 
was admitted to the Ward for Skin Diseases of the Philadelphia Hospital 
in November, 1876. The notes transcribed from my private records are 
as follows: 
Case I—Dennis T., aged 38, an iron-moulder, admitted to the Phila- 
delphia Hospital November 16, 1876. He is a stout, healthy-looking 
man. Fifteen years ago he had venereal disease with buboes, but without 
subsequent signs of syphilis. He has always enjoyed good general 
health, and has never had any disease of the skin until now. It appeared 
about five weeks ago. At the time he was working in the country 
(husking corn), and was in his customary health. He struck his leg 
against something, which caused him to examine the limb, when, to his 
surprise, he found several red spots over the tibia of the left leg. They 
1 Read before the American Dermatological Association at its fourth annual meet- 
ing, at Newport, R. 1., September, 1880. 
1 2 
were unaccompanied by any subjective symptoms. The next day be ob- 
served similar spots in the same region on the other leg. He describes 
them as being the size of small split peas, slightly raised, flat, smooth, 
and dark red. There were about a dozen of them in number. The rest 
of the skin was healthy. On the third day no new developments were 
noticed, but on the fourth day he experienced on the left arm slight itch- 
ing, and on examination discovered on the extensor surface of the left 
arm, from the shoulder to the middle of the forearm, large pin-head sized, 
slightly elevated, dark-red spots. The following night he felt some itch- 
ing on the right arm and on the back, but not enough to cause him to 
scratch, and in the morning noted that similar lesions to those on the legs 
and arm, were here present. They increased very rapidly, and in the 
course of two days they occupied the whole of the back, the buttocks, and 
the thighs. At the end of the third or the fourth day he remembers that 
they were less itchy, and that they then began to increase in size and to 
become slightly scaly, and were in about the same state as now. rlhey 
remained in this condition for a fortnight, when he experienced painful 
swelling of the legs, from the calves to the ankles, which he had never 
before had. For the last three weeks there has been absolutely no itch- 
ing of the eruption. It has become pale in colour, and more scaly, the 
scaliness becoming more marked from week to week. No new lesions 
have appeared since the first week of the attack. The general health 
remained fair during the first week, but afterwards he became subject to 
chilliness, and was unable to stand the cold. About the end of the first 
week, moreover, after the eruption had all appeared, his appetite began to 
fail, and it has not yet returned. He also suffered much headache, which 
has gradually subsided. He states that the chilliness referred to has been 
uninterruptedly present, accompanied with night sweats, but with no de- 
bility nor with pains. The bowels have been irregular. 
Present Condition The eruption begins at the back of the neck and 
extends downwards over the back in the form of an almost solid sheet, 
and over the shoulders and extensor surfaces of the arms to the middle of 
the forearms. With the exception of a few faint lesions over the sternal 
region, the front part of neck, clavicular region, axillte, chest, and abdo- 
men are free; and, excepting a few spots on the flexor surface of the left 
forearm, the flexor surfaces of the arms and forearms have also escaped. 
The disease comes around from the back and includes the sides of the 
thorax, and so finds its way downwards over the buttocks, both surfaces 
of the thighs and legs to ankles. The extensor surfaces are much more 
markedly affected than the flexor surfaces. The genitalia remain free. 
The disease is characterized by pin-head, split-pea, and finger-nail 
sized, superficially scaled, reddish spots, having a dull or dark pinkish 
tint, covered with thin, scanty, whitish, flaky, papery scales, similar to 
those encountered in tinea circinata. They are very slightly raised above 
the surrounding surface; are irregular in outline, some being circular, 
others somewhat angular; and, where numerous, show a disposition to 
coalesce, with the result on the back of the formation of a large, erythema- 
tous, irregularly-shaped patch. The lesions are profuse, especially on the 
back and on the thighs. A placebo was ordered internally, and no exter- 
nal treatment. No diagnosis was made. 
Jan. 10, 1877. The patient has been under constant observation, and 
has had no treatment. The scales were examined with much care with 
the microscope for fungus, but none was found. The lesions have very 3 
gradually become paler during the month; so gradually, however, that 
the change has been perceptible only from week to week. The desqua- 
mation also has decreased, and now is almost unworthy of mention. 
There have been no subjective symptoms. Considerable pigmentation 
has been taking place as the lesions have faded, which is still going on, 
giving the spots a dusky, yellowish, tawny hue. The legs have become 
the seat of large, somewhat thickened, erythematous, scaly patches, closely 
resembling squamous eczema, formed by the coalition of numerous lesions. 
The general health is now good. 
26th. The eruption has faded much more rapidly of late, and the scaling 
and pigmentation are also disappearing, leaving faint, dusky-pink, mottled 
spots. 
HemarJcs The patient remained in the hospital for another week, when 
he was discharged with but the faintest trace of the disease in the form of 
dusky pigmentary stains. His recovery during the last fortnight was 
remarkably rapid. The case was under observation about two months, 
and during this period was the subject of much speculation as to its nature 
and its relation to other well-known forms of skin disease. At the date 
of his admission to the hospital the process was at its height, according 
to his own statement and the subsequent course. After several careful 
examinations, and the lapse of a few weeks, the conclusion arrived at 
was that the disease was entirely new to me, and that, so far as my knowl- 
edge in literature extended, it was a form of disease that had not been 
described. 
Its syphilitic nature was not for a moment entertained, though it pos- 
sessed somewhat the colour of the fading erythematous syphiloderm, and 
had a singularly slow course, and was unattended by subjective symptoms. 
It also bore some resemblance to superficial psoriasis guttata and circinata, 
but far more likeness to both tinea circinata and tinea versicolor, especially 
the former. Its parasitic nature was immediately strongly suspected, and 
careful microscopic examinations were made by myself on repeated occa- 
sions, without, however, discovering any fungus. 
No treatment was employed during the entire course of the process, 
spontaneous recovery taking place in about three months from the begin- 
ning. For some weeks the disease was at a standstill, when without appa- 
rent cause it began very gradually to become paler, and so, for a while, 
by slow degrees faded, and then towards the close rapidly passed away. 
The second case was that of a married lady, the wife of a physician, 
about 30 years of age, whom I was asked to see in consultation with Dr. 
Charles FI. Thomas, of this city, on Nov. 7, 1876. 
Case ll.—Mrs. , set. 30, a lady in the upper walks of life, of rather 
slight frame, though well nourished, with light hair, blue eyes, and fair 
complexion. She has always heretofore enjoyed excellent health, and has 
never had any disease of the skin. The present eruption made its appear- 
ance about a fortnight ago, without fever or other premonitory symptoms. 
She awoke in the morning and found the lesions upon the chest and over 4 
the trunk generally. They neither itched nor burned. Indeed, had she 
not seen them, she would not have been aware of their presence. In the 
course of two days they were as numerous and as well developed as now, 
and looked about the same then as at the present time. The disease, as 
stated, has existed about two weeks, and is characterized by numerous, 
discrete, small patches or spots, which are of the nature of erythematous, 
slight desquamative macules. They are roundish in form, but are some- 
what irregular and ill-defined in outline. These vary in size from a pin- 
head to a split-pea and large finger-nail. The majority are of the size of 
a five-cent silver piece. They are all of a reddish colour, which may be 
further described as being a faded rose-red or a deep dusky-pink with a 
tawny, yellowish cast. They have, therefore, not an acute, but a dull, dusky 
look. They are the seat of slight desquamation in the form of a thin, delicate 
adherent scale, or a layer of partially loose, shrivelled epidermis. The 
scaliness is so insignificant that the epithelium is neither cast off readily 
nor can it be scraped off without difficulty. This feature may be compared 
to that encountered in tinea circinata. The lesions have the appearance, 
however, that they may soon become distinctly squamous. They are on 
a level with the surrounding skin, and possess no border, nor, indeed, any 
defined outline. Passing the hand over the skin, they are noted to be 
dry and somewhat harsh, and the epidermis to be slightly wrinkled. In 
the larger lesions, owing to this shrivelled condition of the epidermis, there 
is a slight, scarcely perceptible depression, due to contraction and pucker- 
ing of the epithelium. Upon pressure, they do not disappear completely, 
less so, for example, than in the case of a similar lesion of psoriasis. They 
are, nevertheless, remarkable for being superficially seated, involving, 
evidently, only the upper layers of the skin, and resemble, not only in 
this respect but also in general appearance, the macules of the erythema- 
tous syphiloderm. The process is evidently a hyperamiia, and not a true 
inflammation. 
The eruption is profuse, and occupies the following regions. The scalp 
and face are free. It begins about the upper part of the neck, and passes 
downwards over the back and over the chest, involving the breasts and 
abdomen, and so on downwards over the hips, buttocks, and thighs to the 
knees. The arms and legs are also affected, but not so much so as the 
other regions named. The forearms and the backs of the hands are only 
slightly invaded. The fingers, palms, and soles remain unaffected. The 
lesions are symmetrical and quite uniformly distributed, and show no dis- 
position to group, nor to be more pronounced in one locality than another, 
though perhaps a better idea of their character can be obtained from those 
on the chest and breasts than elsewhere. They all appear to be in about 
the same stage of evolution; no new ones are observed, nor, on the other 
hand, do any seem to be disappearing. Their colour is paler on the extremi- 
ties than on the trunk. Upon this latter region they are profuse, every 
square line of the surface seeming to be occupied by them. They remain, 
however, discrete. There is little or no itching, nor have there been at 
any time any subjective symptoms. 
The affection bears more resemblance to an extensive case of dissemi- 
nated small-spotted tinea versicolor than to any other disease. As has 
been stated, it also resembles the erythematous syphiloderm, and also 
rbtheln. No treatment was instituted, and no diagnosis was made. 
Nov. 11, 1876. A careful examination of the scales failed to discover 
any sign of fungus, which was suspected. Four days have elapsed, and 5 
no change has taken place except that there has been slight itching and 
that the eruption is somewhat paler. No new lesions. Upon further 
examination of the regions invaded, the lower part of the back and but- 
tocks show larger lesions than elsewhere, and in a more crowded state, 
but nowhere are they confluent. The general health is good. 
Jan. 10, 1877. Four weeks have elapsed since I last saw the patient, 
during which period the eruption completely disappeared. Immediately 
after the last note the disease became worse, the lesions becoming more 
highly coloured, scaly, and irritable, and smarted, but they were not 
itchy. Oil of sweet almonds was now used as an external application, 
and at once gave ease. In a few days decided improvement was noted, 
and in a fortnight the lesions disappeared, leaving slight pigmentation. 
The patient complained that she felt perfectly well during the period that 
the eruption existed, but that as it began to fade she experienced decided 
malaise. 
Remarks—A peculiarity of the lesions in this case is that they mani- 
fested no disposition to coalesce, but remained discrete, though in certain 
regions, as the back and buttocks, they were greatly crowded. The 
majority, moreover, were of a uniform size, which gave the skin a dis- 
tinctly spotted appearance. The desquamation .was lighter than in the 
first case, and could scarcely be called a prominent feature. The lesions 
were rather ill-defined, dry, erythematous macules, evincing no inclina- 
tion to undergo enlargement nor change of any kind. The sudden ap- 
pearance of the lesions here is also worthy of remark, all of them having 
been developed to their full proportion within two or three days. 
The diagnosis, as in the first case (which was under observation at 
the same time), was difficult. The resemblance to an old, irritated tinea 
versicolor was striking, though its occurrence on the thighs and legs was 
at variance with the course of this disease. It was not until several 
careful microscopic examinations had been made that I was willing to 
abandon the idea of its parasitic nature. The sudden invasion of the 
disease, and the x’emarkably rapid development of the lesions, were, of 
course, among the strongest arguments against its probable parasitic 
nature. The likeness, too, to the erythematous syphiloderm, and to the 
exanthem rbtheln, was marked, more so even than in Case 1., and only 
after attentive study were these diseases excluded by Dr. Thomas and 
myself. As in Case 1., there was no treatment instituted, except one or 
two inunctions of oil of sweet almonds, which were employed towards the 
close of the process, and which 1 cannot think were of any positive value 
in hastening the cure. Before they were used the disease had already 
begun to undex-go spontaneous involution. No internal treatment at any 
time was taken. 
The following case was sent to me for an opinion by Dr. Charles Carter, 
at that time Physician-in-Charge of the Northern Dispensary, and is re- 
markable for the widespi'ead extent of the disease. 6 
Case 111 J. S., a large, strong-looking man, about thirty years of 
age, who states that he has always heretofore enjoyed good general health, 
and that he has never had any skin disease before. He is a blacksmith 
by occupation, and is at the present time working in the gas-works, 
where he is exposed to a very high temperature, and is consequently in a 
constant state of excessive perspiration. He complains of feeling weak. 
The disease of the skin made its appearance gradually, having been first 
noticed about six weeks ago. It originally appeared in the form of 
“spots” upon the lateral portions of the thorax, and spread thence down 
the sides of the trunk. Later it invaded the arms and forearms, thighs 
and legs. Its chief force, however, seemed to be expended upon the 
trunk. No change is said to have occurred in the general features of the 
eruption during the last three weeks, it being, in his opinion, during this 
period at a stand-still. 
Upon examination, I find a most extensive disease of the skin in- 
volving the neck, the whole of the trunk, buttocks, groins, genitals, 
thighs and legs, and the arms and forearms. The only regions which 
have escaped are the scalp, face, hands, and feet. From the neck down- 
wards, over the whole of the trunk and the thighs, the eruption is profuse, 
and constitutes a diffuse, almost solid sheet. The axilla;, arms, and fore- 
arms as far as the wrists, are similarly invaded, though from the elbows 
to the wrists the uniformly diseased surface is broken up by small patches 
of sound skin. The legs are affected in this respect like the forearms. 
The eruption is of an inflammatory character, consisting over the trunk 
of a diffuse, uniform, continuous sheet of erythema, or of an erythematous 
inflammation, with but slight infiltration. The skin is smooth, moist 
with perspiration, and feels less supple than normal and slightly thick- 
ened. The colour is a uniform tawny, dusky, dull, faintly violaceous red, 
which he states is brighter or duller as he happens to be at rest or at 
work. No scales can be detected, though by rubbing the fingers over the 
surface small rolls of epidermis may collected, as in the case of an extensive 
tinea versicolor when bathed in perspiration, though to a much less extent. 
Over the back the eruption is less distinctly marked, and is paler in 
colour. Upon the arms it is continuous with that of the trunk, and 
extends to below the elbows as a solid sheet. Over the forearms the 
outline is broken and marked by variously sized, mostly small, split-pea 
sized, circumscribed, flat papular patches, which become fewer towards 
the hands. The same description answers for the legs. The eruption is 
symmetrical. Over the entire affected skin there is a decided tendency 
to a brownish-yellow pigmentation, which, incorporated with the red, 
gives the dusky, tawny tint referred to. He complains only of slight 
itching, except when at work, when it is severe. 
Remarks—l was quite at a loss to make the diagnosis in this case, 
and in the mean time directed the patient to leave off his violent work 
for a week, and requested him to return to me at the end of that time for 
further examination. Microscopic examination of scraped epidermis 
failed to show any signs of fungus. At the end of a week he again pre- 
sented himself, somewhat improved, stating that he had rested himself 
and had kept as free from perspiration as possible. I found that no 
chano-e had occurred in the general appearance of the disease, except that 
the red colour was paler. On the other hand, the brownish pigmentation 7 
was of a deeper tint, and the skin more mottled. A tonic aperient was 
ordered and general directions for diet and hygiene given. I saw him once 
again, a week or ten days later, when no marked change had taken place, 
after which he passed from my observation. 
The disease here invaded the greater part of the cutaneous surface, and 
was indeed almost universal, and as I look back upon the case and its 
history, there seems to me to be little doubt that the wide-spread extent 
of the disease was largely due to the excessively high temperature that the 
patient was almost continuously exposed to. I have forgotten the number 
of the degrees, but it was so high that his co-laborers not infrequently suc- 
cumbed to the heat. The perspiration which took place he stated was exces- 
sive, and large draughts of water were continually indulged in. Even when 
I saw him after a half day’s rest he was bathed with moisture, and was still 
sweating freely. This circumstance, moreover, I have no doubt inter- 
fered in a measure with the natural course of the disease, and offers an 
explanation for the absence of desquamation. There were no circinate 
lesions, and the few discrete ones that existed on the extremities were 
small and maculo-papular in character. The lesions, therefore, were of a 
macular type, and over the greater portion of the surface were so confluent 
as to constitute a uniform, solid sheet of disease, such as is sometimes met 
with in lichen ruber. This disease, indeed, suggested itself to me in the 
matter of diagnosis, but the history as well as other points at once excluded 
it from the list of probable diseases. Tinea versicolor also came to my 
mind, although I could scarcely conceive of this disease assuming such 
proportions ; the brief length of time of its existence, and later the micro- 
scope dispelled the idea. Other inflammatory diseases, occasionally in- 
volving large surfaces, such as erythematous eczema, pityriasis rubra, 
psoriasis, and dermatitis exfoliativa, did not occur to me, and need be 
mentioned here only to be dismissed, for the symptoms had no positive 
likeness to any of these diseases. 
Of the next case which presented itself I shall give only a brief account, 
for the reason that it differs in no way from another case which has oc- 
curred more recently, and which I shall describe in detail. The patient 
was a young milkman, who presented himself to me on Nov. 13, 1878. 
Case IV.—Hugh S., act. 22, a spare, consumptive-looking person, with 
light hair. He states that his general health is equal to the average, and 
that he never had any disease of the skin before. It began six weeks ago 
in the form of small “ ringworm-like spots,” occupying the abdomen, sides 
of the thorax, and thighs. The lesions rapidly, and soon attained 
their present proportions. He is unable to give any further account of 
their development, as inasmuch as they gave him but little annoyance he 
seldom inspected himself. He had been told they were ringworm, and 
that they would in time disappear, but as lately they had increased in size 
and vvere rapidly invading new regions, and had moreover resisted sulphur 
ointment, used as a parasiticide, he had sought further advice. 8 
The disease occupies the sides of the thorax, the chest, from the clavicular 
region down, the abdomen, groins, and the thighs as far as the knees. 
It is symmetrical. It consists of a large number of both discrete and 
confluent, circular or ovalish, more or less annular, slightly scaly, dull red- 
dish, erythematous patches having a pale, dusky-yellowish tinge. The 
colour is uniform, being nowhere patchy. Over the upper part of the trunk 
the lesions are confluent, and form a solid sheet of eruption, completely 
encasing the regions, in the manner sometimes seen in extensively de- 
veloped tinea versicolor. The disease on these patches is slightly scaly, 
the scales being small and mealy or branny in character, resembling also 
the desquamation of tinea versicolor. Passing the hand over the surface 
the skin is not noticed to be harsh, nor to be in any way markedly altered. 
It is but very little thickened, and is quite supple. 
About the abdomen, groins, and upper third of thighs distinctly defined, 
more or less circular and ovalish lesions exist, some of which the patient 
states are recent. They resemble in general appearance the well-known 
lesions of tinea circinata, having a marked reddish border with a pale-red, 
slightly scaly, central area, the disease having the look of spreading on 
the periphery and of clearing in the centre. These lesions are of variable 
size, some being as large as a silver quarter dollar, others, ovalish in shape, 
of the size and shape of pecan-nuts or olives. Here and there they are 
confluent, though they do not coalesce unless overcrowded. The patient 
complains of some itching and heat of skin, owing, doubtless, to the free 
use of sulphur ointment which he has just applied. Before this application 
there was no itching. A plain starch dusting powder was ordered, and 
internally a magnesia aperient. 
December 9th. The disease during the past month has decreased in ex- 
tent and in severity, and has cleared away at many points, but new circi- 
nate lesions have made their appearance on the thighs, which now resemble 
eczema squamosum moi'e than tinea circinata. The older ones, however, 
still bear a strong likeness to the last-named disease. Petroleum ointment 
and calomel, a half drachm to the ounce, was ordered. 
March 1, 1879. The patient informs me that shortly after his last visit 
the disease began to become perceptibly paler, and more scaly, and that it 
then began to clear away rapidly here and there, until, at the end of a 
month, the skin was normal though slightly discoloured and tawny. At 
the present writing his skin is healthy, showing no trace of the former 
affection. It has been so for four or five weeks. The general health of 
the patient remained good throughout the entire course of the disease 
The next case presents the disease in still another form, though really 
differing from the others, I think, only in the degree of development. But 
the lesions were so different, as to size and shape, that at first I was slow 
in recognizing the affection. The patient was a young man who presented 
himself for advice at the department for skin diseases of the Hospital of 
the University of Pennsylvania. 
Case V.—Henry G., 27 years of age, a porter by occupation. His 
family history has no bearings on the disease. He has always enjoyed fair 
health, but has suffered for several years from dyspepsia and constipation. 
He has never, to the present attack, suffered from any kind of skin disease 
excepting an affection which was called at the time (twelve years ago), 
the “ itch” and which was cured. 9 
His present disease is of three weeks’ duration. For some weeks pre- 
viously he had been performing unusually heavy work in a warm atmos- 
phere, and was during this time almost constantly in a state of more or 
less profuse perspiration. His attention was first called to it by an attack of 
itching, confined to the axillas, which came on one evening as he was un- 
dressing himself. On examining the arm-pits he found a number of 
raised dry lesions, of a reddish colour, and which burned and itched. 
Throughout the night these symptoms continued at intervals. While 
dressing in the morning they seemed almost intolerable, but when once 
dressed and at work the annoyance ceased and he quite forgot the exist- 
ence of the eruption. A few days later while changing his clothing he 
experienced some irritation in the skin on both sides of the trunk, and 
thrusting his hand under the flannel shirt, which he wore next the skin, 
he rubbed and scratched himself vigorously. As this seemed to aggravate 
the symptoms, he took off his shirt, and, to his surprise, found that the 
eruption had extended from the axillae down along the lateral portions of 
the trunk, reaching as far as the crest of the ilia, and was beginning to 
extend over the abdomen. 
It spread slowly until the sides of the hips as low as the trochanter, to- 
gether with the groins, pubes, and, to a slight extent, the perineum, be- 
came involved. Within the last few days the affection has made more 
rapid progress, involving the upper part of the thigh in a single isolated 
patch. The itching and burning have become steadily worse, until now 
he cannot rest at night. Such was the history given. 
On examination I find the eruption to be limited almost exclusively to 
the lateral portions of the trunk and to the lower part of the abdomen and 
to the groins. Beginning in the axillae on either side, it extends symmetri- 
cally down both sides of the trunk, becoming gradually more marked until 
the crests of the ilia are reached, where the eruption is at its maximum, 
and then turning inward to involve the inguinal regions with the upper 
and inner parts of the thigh and the pubic and lower abdominal regions. 
Small patches of eruption exist on either arm in the flexor surface of 
the elbow, and a recent patch has shown itself upon the posterior aspect 
of the thigh. No other areas of actual disease can be observed, but the 
integument generally is in an irritable condition, as is shown by the oc- 
currence of cutis anserina on the least exposure, as well as the tendency 
to the formation of urticaria-like elevations about the papules when these 
are rubbed, and ready flushing of the skin when any part is lightly chafed 
with the hand. 
Viewed as a whole, the eruption is seen to consist of very numerous, 
variously sized, from pin-head to pea-sized, maculo-papules of a bright or 
dusky red colour, widely scattered or grouped in disorder, coalescing fre- 
quently to form patches which often present an indistinctly circulate form, 
the centre being occupied by a patch of dirty-yellowish, brownish pig- 
mented, smooth or slightly scaly skin. When the hand is passed over the 
surface, a slight nutmeg-grater sensation is felt. The initial lesion, and 
the one which is by far the most numerous, is a minute pin-point to large 
pin-head sized, bright-red, maculo-papule, sharply defined, without areola, 
and losing colour under pressure. Occasionally a minute quasi-vesicular 
point may be noted on the apex of a discrete papule which then most 
closely resembles the lesion of ordinary miliaria rubra. More frequently 
the lesion retains the papular form and is joined by others, the patch 
growing larger and larger, the individual papules becoming flattened and 10 
merging to form a patch. In the older lesions the centre of this patch 
becomes absorbed, sinking to a level with the surrounding integument, 
and forming an area of pigmented skin, around the edges of which new, 
often discrete, papular lesions can be seen. 
The lesions appear to be unconnected with the hair follicles. Sweating 
increases the activity of the eruption, which then itches intensely. The 
single lesions and the smaller patches are not markedly scaly, but the 
larger patches have a few light, fine, grayish scales upon their surface. 
The patient’s general condition shows signs of disturbance of the bodily 
functions generally and particularly of the digestion. He sweats freely, 
and has suffered a good deal with headache until the last few days, and 
now experiences frequent sensations of chilliness. His appetite is poor 
and is capricious ;he craves various articles of diet. He suffers occasional 
nausea but has never vomited. His bowels are constipated. He is low- 
spirited, pale, and rather haggard, and feels weak. A fortnight later all 
trace of the disease had disappeared, leaving the skin in a natural state. 
Microscopic examination failed to reveal any vegetable parasite. 
Remarks—The peculiarity of this case is the fact that many of the 
lesions assumed a distinctly maculo-papular form, the greater number re- 
taining this form throughout their evolution. Only here and there did 
they coalesce, and in no instance to the extent of constituting large patches 
as in the other cases reported. It is true they were only slightly elevated, 
but they were nevertheless fully entitled to be designated maculo-papules, 
being pin-head to split-pea sized, sharply circumscribed, moderately firm, 
and inflammatory. 
I can describe their appearance no better perhaps than by stating that 
they resembled certain forms of papular eczema where the lesions are flat 
rather than acuminated. They also resembled somewhat the first stage of 
lichen ruber planus. On account of the papular form, the resemblance to 
tinea circinata was not stinking, though the few circinate lesions were so 
suggestive as to cause a careful microscopic examination to be made. 
Nor, for the same reason, was there any ground for thinking the disease 
to be a form of tinea versicolor. As stated in the notes, the patient was 
in excessive perspiration from over-exertion and debility on both occa- 
sions when I examined him, especially so in the first instance, which would, 
of course, account for the absence of desquamation. On the second occasion 
his skin was also somewhat moist, though, as stated, furfuraceous scaling 
was then observed. The lesions, moreover, being mostly discrete and 
small, marked desquamation would scarcely have taken place under any 
circumstances. The next point of interest is the rapid course of the dis- 
ease, entirely uninfluenced by treatment, whether internal or local. The 
lesions were of three weeks’ standing when I first saw them, and were 
then already undergoing involution. A fortnight later the process had 
terminated in recovery, the improvement during the last week having 
taken place rapidly. 
The following case was sent to me for an opinion by my friend, Dr, 
Elliott Richardson, of this city, who subsequently kindly gave me the 11 
opportunity of seeing the patient from time to time until complete recovery 
took place. The date at which this case came under observation was 
Feb. 10, 1879 
Case VI.-—Mrs. Catherine E., jet. 48, married, a large, fleshy woman, 
accustomed to washing and to heavy work in general. She relates that 
though stout and apparently in good health at the present time, she is in 
reality weakly and unwell. Her appetiteis capricious, being ravenous at 
times and on other days without any desire for food. She has for years 
been subject to prickly heat during the summer, but has never had it in 
winter, though she ordinarily perspires freely throughout the entire year. 
The present skin disease is the first affection of the skin she has ever 
experienced. It is of four weeks’ duration, and manifested itself on the 
breasts in the form of a distinct ring about the size of a five-cent silver 
coin ; at the same time she remembers that there were three or four small 
papules in the flexure of the left arm. A few days later, both rings and 
papules appeared over the sides of the trunk and elsewhere, accompanied 
by decided itching from the beginning. The eruption spread with rapidity, 
only two weeks elapsing before it was at its height and had invaded all 
the regions now involved. For the past fortnight it has been at a stand- 
still. It has at no time been more inflammatory than now, nor, indeed, 
in any way different. 
It consists of a profuse ex-uption made up of solid erythematous patches, 
and rings with clear centres, and of numerous, crowded and conflu- 
ent, variously sized, flat, slightly raised maculo-papules. The patches 
consist of variously sized, mostly large, hand-sized and larger, areas 
of erythema, of a mottled red colour, the seat of furfuraceous des- 
quamation. The annular lesions, or rings referred to, are also numerous 
and conspicuous. They vary in size from a silver five-cent piece to a 
quarter dollar, some being even larger, the majority, however, being 
of the size of five and ten-cent silver coins. They are circular or ovalish 
in outline, but where two or more have run together, irregular forms 
result, which in some cases have a diameter of several inches. They pos- 
sess a slightly raised, defined, reddish border, with a paler, discoloured, 
or mottled, decidedly scaly centre, the scales being fine and mealy or 
branny, as in tinea versicolor; in some cases they are coarser and then 
resemble the scales of tinea circinata. The maculo-papular lesions spoken 
of are of various size and shape, some being pin-head sized, others as large 
as split peas, while in shape they are roundish or more or less irregular 
or even angular. The smaller ones resemble the papules of prickly heat, 
and it is this affection that the patient thinks she is suffering from. They 
are flat or rounded, and are slightly raised, but are not so firm as in papu- 
lar eczema. On the contrary, they can barely be detected in passing the 
hand over the surface; still, they have the appearance of being plastic. 
They are bright red in colour, are smooth, and are without scale. 
The following regions are invaded. The disease begins at the nape of 
the neck, and extends down over the whole of the back, over the buttocks, 
hips, and thighs to the knees. In front it begins about the clavicles and 
spreads over the shoulders and arms, and invades the axillte, sides of the 
thorax, mammte, and abdomen and groins; the regions of the umbilicus 
and pubes alone escaping. The whole trunk may therefore be said to be 
involved, and over most reigns in the form of a solid sheet of eruption. 
It is symmetrical, neither side being favoured. The rest of the general 
surface is free. 12 
Over the upper part of the back, the disease is in the form of large solid 
patches, terminating above the shoulders with a sharp somewhat angular 
line of demarcation, but below, the border is ill defined with out-lying 
smaller patches and discrete papules; about the region of the spinal column 
and over the lumbar region, the lesions are mostly small and papular in 
character. Upon the sides of the thorax and over the chest solid patches 
are encountered. Over the breast they are maculo-papular, and in small 
areas the size of a split pea and finger nail, some of which are discrete, 
others confluent. The abdomen is the seat of large hand-sized, more or 
less broken-up patches, irregular in outline, and altogether ill defined. 
In the groins and on the thighs distinct, circular or ovalish, annular 
lesions are met with, resembling precisely in appearance tinea circinata 
occupying these regions. The larger rings are plainly formed by the coa- 
lition of two or more smaller ones. In the groins, in the axillag, and 
beneath the mammse, which are pendulous, the skin is red and slightly 
macerated, constituting slight erythema-intertrigo, but nowhere are there 
signs of eczema. 
The various lesions appear to be in different stages of development. 
Old and new spots are seen side by side, and solid patches, rings, and 
papules occur likewise in close proximity to one another. It is evident 
that these various forms, namely, macules, papules, rings and extensive 
patches, are, in many instances, but stages of one another, the maculo- 
papules being the first stage; the circinate, more or less annular lesions, 
the second stage; and the larger solid patches the last stage. As stated, 
the smallest lesions are smooth and free of scale, but the rings, even the 
smaller ones, show generally decided dryness and desquamation, and a 
tawny, dusky, yellowish hue, which reminds one of the colour of tinea 
versicolor. They are, moreover, more scaly on the periphery than in the 
centre. The patient complains of considerable itching and of pricking 
sensations, reminding her of her experience in former attacks of prickly 
heat. 
March 2. During the past fortnight the disease has been gradually 
becoming paler, and in some localities has shown signs of clearing away. 
Upon the breasts, the regions where it first appeared, it is much mottled 
and broken up, and is pale, tawny, and decidedly scaly. It is everywhere 
less itchy. No new lesions have appeared. 
10th. The process of involution has been going on rapidly. The erup- 
tion has faded perceptibly within the week, and is now of a pale dusky 
pink or violaceous colour, with a distinctly marked brownish-yellow tinge 
pervading the whole, giving the skin a dingy, soiled look. It is, moreover, 
the seat of a marked furfuraceous desquamation. The itching has entirely 
ceased. 
April 1. The redness has disappeared, but there still remains a general, 
mottled, pale brownish-yellow, tawny pigmentation, which, however, is 
gradually fading. The desquamation ceased a week or longer ago. 
23d. The skin has regained its natural appearance, and the patient is 
discharged from further observation. 
I have thus in the six cases presented described a disease which has 
caused me much embarrassment, especially in the earlier cases which 
came under observation. It is, moreover, an affection which I have no 
hesitation in stating merits careful study and further investigation. Notes 
of the six examples reported seem to me quite sufficient for the purpose of 13 
portraying the chief characters of the disease and enabling one to recognize 
the lesions. 1 may, however, add that four additional cases of the disease 
have, within the year or past eighteen months, come to my notice, in all 
of which the main symptoms were well displayed. From these observa- 
tions, I think it may be stated that the pi-ocess is a clearly defined one as 
regards its clinical features, which are very similar in all cases. Not only 
are the lesions alike, as concerns colour, form, size, and general character- 
istics, but the regions involved, and the course and evolution of the dis- 
ease are also almost the same in each instance. The disease appears to 
me to be a well-marked process, and to be as distinct from other diseases as 
it is possible to imagine. I cannot believe that it is a form or an unde- 
scribed variety of any of the well-known dermatoses. 
The disease has, as far as my knowledge extends, never been described 
in this country, nor have I ever encountered in our literature reports of 
peculiar cases of skin disease which it occurs to me could be considered 
as the same affection. No more do we find any description or mention of 
such a disease in any of the English works on dermatology, whether of 
old or of recent publication, nor in any of the many treatises on the subject 
which have been issued from the German press. It is, indeed, singular that 
such a well-defined disease should have escaped the notice of both English 
and German observers. From my knowledge of the process, Ido not think 
it possible that it could be regarded as other than a distinctive affection by 
such acute observers as now occupy the dermatological field in England 
and in Germany. To the French, however, belongs the honour of having 
first described the disease, though, as it appears to me, rather imperfectly, 
and it is on this account, I think, that their writings on this disease have 
not attracted much attention even in their own country. It is only quite 
recently—since, indeed, I began to prepare this communication—that I 
became aware that the disease had been described in France. While, 
therefore, the question of priority in the description does not concern the 
writer, I may be permitted to state that the disease has been familiar to 
me for some years, and that the notes here given were recorded at the 
date of each observation, and therefore prior to my acquaintance with 
French writings on the subject. 
Bazin, in his work on “ Les Affections Generiques de la Peau,”1 con- 
siders the subject of pityriasis at length, defining it to mean “ a disease of 
the skin in process of evolution, characterized during its period of exist- 
ence by fine, dry, furfuraceous or foliaceous scales seated upon the tegu- 
mentary surface without appreciable elevation above the surrounding parts, 
covering a more or less considerable area, with or without change in the 
colour of the skin.” He divides pityriasis into two forms, one due to ex- 
ternal causes, as from the razor and from the parasite microsporon furfur, 
1 Paris, 1863, p. 331. 14 
and the other to internal causes, of which he makes two varieties, namely, 
“pityriasis arthritique” and “pityriasis herpetique.” Under the head of 
the former we find “ pityriasis rubra aigu” with the two varieties “ macu- 
lata et circinata.” There are other points of refinement in classification 
given, which, however, need not be mentioned here, for my chief object 
in quoting the views of this eminent French author is to show that he 
was entirely familiar with the clinical features of the disease in question, 
as will be readily admitted from the following description. Pityriasis 
rubra aigu, he proceeds to say, is an affection characterized by red macules, 
disseminated and small, forming sometimes by their coalition large patches, 
covered with grayish or whitish furfuraceous scales, and terminating by 
resolution in the course of from two to four weeks. The prodromata 
consist of malaise, anorexia, and a more or less marked febrile state. In 
addition the eruption is accompanied by tolerably severe itching. 
According to the aspect of the eruption, Bazin makes two varieties, 
pityriasis maculata and pityriasis circinata. The first of these (which, 
according to this writer, is the same disease as the pityriasis rosea of 
Gibert) is characterized by 
“pale red macules, small and disseminated, non-elevated, and more or less 
rounded, with sinuous outlines. In the second variety, pityriasis circinata, the 
eruption manifests itself in the form of small, disseminated, red macules, resem- 
bling those of psoriasis guttata. They soon unite and constitute circles more or 
less complete, which resemble those of tinea circinata (I’herpes circinti) ; or they 
form linear bands and semicircles, which call to mind psoriasis (Ihpre valgaire). 
“Nevertheless, pityriasis rubra circinata differs in the absence of elevation 
from that which pertains to both psoriasis and tinea circinata. In the beginning, 
the macules are the seat of a slightly lamellar exfoliation, which later becomes 
furfuraceous. In both varieties the general symptoms cease with the development 
of the eruption, but the itching persists throughout the entire course of the disease. 
Often it is so intense as to cause scratching, under the influence of which a transi- 
tory eczematous desquamation takes place. The disease ordinarily develops upon 
the face, scalp, and, above all, on the trunk; sometimes also it is encountered 
on the limbs, notably on the forearms and on the lower part of the legs. The 
affection varies in its course and duration. It disappears sometimes in from ten 
to fifteen days ; in other cases it continues for a month or five weeks by successive 
outbreaks. But it ends always by resolution, never passing into a chronic state. 
It is observed principally in youth. Cold, irregularities of diet, and the suppres- 
sion of the perspiration occasion more particularly the disease. The influence of 
spring also contributes to its production. The primary lesion is a congestive 
macule accompanied with lamellar and furfuraceous desquamation.” 
Finally, in a diagnostic point of view, it must be distinguished from 
certain diseases which it resembles, such as urticaria, “simple roseola,” 
and the other varieties of pityriasis, especially from “ pityriasis rubra 
chronique ou inflammatoire” (which is the pityriasis rubra of Hardy, 
Devergie, and other writers). The disease we have been considering, 
according to Bazin, always terminates by resolution, having a natural 
tendency to recover. The cure may, however, be hastened by the use of 
alkaline or starch baths, cooling beverages, and laxatives. 
From this description, which I have quoted at length to prove that 
the disease is the same we have been investigating, it is manifest that it 15 
was well known to this dermatologist. As intimated, he moreover states 
that it was even familiar to Gibert, his predecessor at the “ St. Louis,” 
who termed it “pityriasis rosea,” but in the edition of Gibert’s work1 at 
command lam unable to find any account of the affection. To Bazin, I 
think, undoubtedly belongs the honour of having first described it. Shortly 
after, it was also recognized by Hardy and briefly described by him in the 
second edition of his Lemons sur les Affections Outanees Dartreuses under 
the name “ pityriasis circine.” In the third edition of this work2 he 
makes four varieties of pityriasis, namely, pityriasis rubra, pityriasis 
pilaris, pityriasis circine, and pityriasis alba. Concerning pityriasis rubra 
(which, it may be remarked, is not very clearly portrayed), pilaris, and 
alba it is not necessary here to speak. 
“In pityriasis circin6,” he says, “the epidermis, as in eczema and psoriasis, 
affects a circular disposition and a regularity which is very clearly and well defined. 
Apart from this particular the objective symptoms are those which belong to 
pityriasis in general. Thus, we see disseminated upon different parts of the body 
a variable number of disks or of segments of circles from two to three centimetres 
in diameter, of a rosy colour in the beginning and covered with fine epidermic 
scales, more abundant and denser on the periphery than in the centre, and giving 
sometimes a slight grayish tint to the skin, especially when the patches are nu- 
merous and close to one another. Within six weeks or some months the patches 
run their coux’se. The redness vanishes, and the scales disappear, leaving some- 
times in their place only a mealy dust. The itching and the smarting, while 
never obtaining a great degree of intensity, are nevertheless sometimes very dis- 
agreeable. The chief point of this affection is its similitude with tinea circinata 
(I’herpfcs cix’cine), and the real difficulty of distinguishing them at first.” 
In speaking of the diagnosis between these diseases, he says:— 
“ It is very important in a practical point of view to distinguish them, for while 
they resemble each other in their exterior aspect they are far removed ixx their 
nature and origin, the one being a parasitic affection, the other a dartrous disease. 
“ In the first place each of the diseases has its special teiritory, and they rarely 
manifest themselves ixx the same regioxxs ; but this point is only of moderate im- 
portance and is altogether secondary ;in an attentive comparison of ,the diseases 
we find other differential characters of value. Thus, in pityriasis the patches 
are numerous, less extensive, and remain fixed in their dimensions during the 
entire coux-se of the disease. The disks of tixxea cii'cina, on the contrary, are as a 
rule less numerous ; they are, in the beginxxing, also confixxed, as in the case of 
pityriasis, but soon they extend themselves centrifugally very rapidly and pro- 
nouncedly, and at the same tixxxe that the periphery invades the neighbouring 
parts the centre recovex's in a manner, so as to form a ring of which the circum- 
ference, scarcely raised, presents vesicles or small pustules, which never exist ixx 
pityriasis. Finally, the microscopical examination will dissipate all doubt, if any 
such still exists. There only remains to be mentioned the likeness which stands 
betweexx pityriasis circinata and psoriasis circinata. The xxxore marked dispositioxx 
of the patches, their thickness, and the manner of imbrication and the tenacity 
of the scales in psoriasis, together with the tuxnefaction and the special redness of 
the skin, render an error alixxost impossible.” 
From this description it will be seen that the author is evidently treat- 
ing of the same disease as that being considered, but the account is too 
brief to be of much value, as from it one could scarcely recognize some of 
the cases that 1 have here reported. 
1 Traite Pratique des Maladies de la Peau. Paris, 1840. 
2 Paris, 1868. 16 
More recent French writers, on the other hand, as Gailleton1 and Gui- 
bout,2 do not seem to be familiar with the disease, as no mention is made 
of it in their respective works. This occurs to me as being all the more 
singular, when we reflect that the former author is “ ex-chirurgien en chef 
de I’Antiquaille,” at Lyons, the hospital where the observations of Horand 
(about to be referred to) were noted, and that Guibout, one of the staff 
of the St. Louis, has long been identified with this hospital, the scene of 
the studies of Bazin and of liardy referred to. Moreover, I have looked 
in vain, with one exception, for any reference to or mention of the affec- 
tion we are considering throughout the numbers of the journal which is 
the exposition of French dermatology—the Annales de Dermatologic et 
Syphiligrapkie. The exception is an article by M. Horand, surgeon to 
the “ Antiquaille,” entitled ‘‘Notes pour servir a ITiistoire du pityriasis 
circine,” which appeared in the periodical cited in 1875-1876.3 
In this communication Horand premises his observations by stating that 
there exists a disease of the skin, that he has encountered in children, of 
which the diagnosis was embarrassing, and of which moreover almost no 
information was to be derived from dermatological Avorks. The Avriter 
continues that Hardy alone mentions the affection, but in a manner so 
insufficient that its characters would scarcely be recognized. He then 
proceeds to give the notes of seven cases, all occurring in children, the 
descriptions being sufficiently detailed and so accurate that upon a careful 
perusal of the article I had no hesitation in concluding that the disease 
was the same that I had from time to time encountered, but chiefly in 
adults, and which had to me also proved a source of embarrassment in 
diagnosis. I shall not Aveary you, gentlemen, by quoting the particulars 
of these cases, but in justice to M. Horand I shall present his descrip- 
tion of the disease together with such other information as may seem of 
value. This is the more important, as his observations, as you avOI note, 
differ in several points from the account of the disease presented by me. 
“This affection,” says M. Horand, “has its seat upon the neck, trunk, and 
limbs, but manifests itself especially on a level with the scapular, deltoid, and 
sub-clavicular regions. It is made up of discrete or confluent patches, of Avhich 
the dimensions vary ordinarily between those of a lentil and those of a tAVO-franc 
piece. It is only in rare instances that they exceed these dimensions. The 
patches are scarcely raised above the level of the skin, rounded, and the smaller 
ones plentiful; the others are depressed in their centre, that is to say, their bor- 
der alone is prominent, Avhich gives them a clearly defined circinate form. Their 
colour varies from a pale-rose to a whitish-yellow, approaching so much the tint of 
the neighbouring skin that it is sometimes Avith difficulty that they can be distin- 
guished from the rest of the integument, if the precaution be not taken of placing 
the patient in an oblique light for examination. Frequently the border alone is 
colored. 
“ The patches are always dry, the surface being more or less furfuraceous, and 
the tissues beneath supple, and neither thickened nor inflamed. The skin, sepa- 
1 Traite Elementaire des Maladies de la Peau. Paris, 1874. 
2 Lejons Cliniques sur les Maladies de la Peau. Paris, 1876. 
3 Tome vii. No. 5. 17 
rating one lesion from another, remains healthy. Finally, they are accompanied 
sometimes with a slight itching, of the kind that under the influence of the irri- 
tation produced by the scratching causes them to redden. Nevertheless, they 
do not occasion any inflammatory phenomena during the course of their evolu- 
tion, of which the duration cannot be determined in a precise manner. The 
eruption may persist several months, if the patient fails to employ treatment; 
but notwithstanding its long duration the characters do not change, and the 
patches appear to retain throughout the period of their existence their original 
dimensions. Finally, after the disappearance of the disease no trace of its tran- 
sition remains.” 
M. Horand continues: “It is with design that in each of the cases reported I 
have passed over in silence the result of the microscopical examination, reserving 
it for mention here. In no case has this examination been neglected; in each 
instance 1 can say that it was made with the greatest care, for the purpose of 
ascertaining whether or not the affection was due to a parasite. I took care to 
macerate the epidermic dust, obtained from scraping the patches, for twenty-four 
hours in ether ; of washing it with alcohol after the evaporation of the ether, and 
of preserving the preparations in glycerine and in acetic acid. But never having 
found the elements which characterize the vegetable parasites, I believe that I am 
authorized in maintaining that this cutaneous affection is not of a parasitic nature. 
It does not appear, moreover, to be contagious, notwithstanding that I have been 
called to treat two brothers suffering with the disease, for both had been exposed 
to the same causes for contracting it, that is to say, both had been in bad hygienic 
surroundings. As to the general health of patients, it is ordinarily very good.” 
M. Horand proceeds to say, that “in seeking for a place in which to classify 
the affection, we observe that it is a dry disease, consisting essentially of a very 
fine furfuraceous desquamation, and that it therefore belongs to the group • pity- 
riasisique.’ Moreover, the circinate form and the definite dimensions which the 
patches assume constitute important characters of the eruption—in fact, a parti- 
cular variety. The name which appears the most suitable for designating the 
disease is that of pityriasis circine.” 
The writer next gives his reasons for considering it the same affection 
as the pityriasis circine of Hardy, and as a different disease from the 
pityriasis circinata of Bazin. Upon the latter point I must, however, dif- 
fer with M. Horand, for it seems plain to me that Bazin’s description, as 
I have given it, portrays the disease so accurately that one could scarcely 
mistake it. While the account of the disease as narrated by Hardy is per- 
haps more graphic and certainly more concise, yet I think no one can 
question that Bazin was equally familiar with the process, and that he 
doubtless included other forms in his description. Horand next points 
out the differential diagnosis from the “erytheme centrifuge de Biett,” 
from tinea versicolor (pityriasis versicolor), and from tinea circinata 
(herpes circine); and finally mentions the treatment that he has found 
most efficacious, which consists of baths, either with sulphide of potassium 
or sub-carbonate of sodium, and of frictions with black soap, or of alkaline 
or mercurial ointments. He adds that the eruption presents no gravity, 
and that its treatment is of the simplest kind. This concise and admira- 
ble article does not seem to have attracted the attention of which it was 
deserving. A brief abstract appeared in the Vierteljahresschrift fur Der- 
matologic und Syphilis, with a short criticism by the editor, who, from 
his remarks, evidently fails to recognize in the description a distinctive 18 
disease, or even any value in the communication, for he concludes the ab- 
stract by saying that 
“inasmuch as the author acknowledges that in several cases he has found the 
disease associated with eczema and impetigo, the interpretation of the disease as 
pityriasis rubra, i. e., the squamous stage of eczema, will doubtless prove that 
which will for the most part stand the test.’’ 
A similar abstract of the paper, by Dr. James C. White, also occurs in 
the Boston Medical and Surgical Journal, Dec. 7, 1876. 
Concerning the name pityriasis maculata et circinata, I have at present 
but little to say, for my object in this communication is to bring forward 
the clinical features of the disease, and not to enter into a discussion upon 
nomenclature. I would only add that at present I see no reason for sug- 
gesting a new name for the disease, especially as the terra has long been 
employed by both Bazin and Hardy. Moreover, the name expresses the 
chief features of the disease sufficiently clearly for practical purposes. 
While it is not my intention now to consider the subjects of the etiology, 
pathology or diagnosis of the affection, I cannot refrain from briefly re- 
marking upon the matter of diagnosis that the disease, in my opinion, is 
distinctly defined from eczema squamosum, psoriasis, seborrhoea, lichen 
ruber, and from pityriasis rubra, as described in my “ Treatise on Diseases 
of the Skin.” The relation which it may have to the pityriasis rubra of 
other writers is a question too extensive to be engaged upon here. 1 my- 
self cannot view the process as in any way related to this disease. The 
likelihood of its being a vegetable parasitic affection must also, I think, 
be definitely excluded. 
In reviewing the chief characters of the disease, as depicted by Hardy, 
Bazin, and Horand, I note certain points of difference between these ob- 
servers, especially the two latter, and myself, some of which are of such 
importance as to call for remark. In the first place the natural history of 
the affection is not clearly brought out by either observer, but little infor- 
mation being given concerning the primary lesions and their subsequent 
evolution and involution. Thus, neither speak of the rapid, and in some 
cases insidious, development of the lesions; nor of the great extent of sur- 
face which may be involved; points, I think, of importance. Neither 
observer, moreover, refers to a prominent symptom, namely, pigmentation, 
which in all of my cases was a conspicuous feature. The spontaneous in- 
volution of the process, although variable as to time, is also worthy of 
special remark. Horand observed the disease in children only, the ages of 
his cases varying between seven and thirteen. Mine were all in adults. 
I mention this particularly because the circumstance aids in explaining 
certain points of difference between this writer and myself, such, for ex- 
ample, as colour and elevation of the lesions, pigmentation, thickening of 
the skin, extent of disease, and the history. The cases reported by me 19 
manifestly portray a much more extensive and formidable disease than 
do those of Horand, and the two series are therefore both valuable in that 
they supplement each other, and taken together afford considerable infor- 
mation concerning the process.