#Later Lesions.#—­In the skin and subcutaneous tissue, the later manifestations may take the form of localised gummata, which tend to break down and form ulcers, on the leg for example, or of a spreading gummatous infiltration which is also liable to ulcerate, leaving disfiguring scars, especially on the face.  The palate and fauces may be destroyed by ulceration.  In the nose, especially when the ulcerative process is associated with a putrid discharge—­ozaena—­the destruction of tissue may be considerable and result in unsightly deformity.  The entire palatal portions of the upper jaws, the vomer, turbinate, and other bones bounding the nasal and oral cavities, may disappear, so that on looking into the mouth the base of the skull is readily seen.  Gummatous disease is frequently observed also in the flat bones of the skull, in the bones of the hand, as syphilitic dactylitis, and in the bones of the forearm and leg.  When the tibia is affected the disease is frequently bilateral, and may assume the form of gummatous ulcers and sinuses.  In later years the tibia may present alterations in shape resulting from antecedent gummatous disease—­for example, nodular thickenings of the shaft, flattening of the crest, or a more uniform increase in thickness and length of the shaft of the bone, which, when it is curved in addition, is described as the “sabre-blade” deformity.  Among lesions of the viscera, mention should be made of gumma of the testis, which causes the organ to become enlarged, uneven, and indurated.  This has even been observed in infants a few months old.

Occasionally a syphilitic child suffers from a succession of these gummatous lesions with resulting ill-health, and, it may be, waxy disease of the internal organs; on the other hand, it may recover and present no further manifestations of the inherited taint.

Affections of the Eyes.—­At or near puberty there is frequently observed an affection of the eyes, known as chronic interstitial keratitis, the relationship of which to inherited syphilis was first established by Hutchinson.  It occurs between the ages of six and sixteen years, and usually affects one eye before the other.  It commences as a diffuse haziness or steaminess near the centre of the cornea, and as it spreads the entire cornea assumes the appearance of ground glass.  The chief complaint is of dimness of sight, which may almost amount to blindness, but there is little pain or photophobia; a certain amount of conjunctival and ciliary congestion is usually present, and there may be iritis in addition.  The cornea, or parts of it, may become of a deep pink or salmon colour from the formation in it of new blood vessels.  The affection may last for from eighteen months to two years.  Complete recovery usually takes place, but slight opacities, especially in the site of former salmon patches, may persist, and the disease occasionally relapses. Choroiditis and retinitis may also occur, and leave permanent changes easily recognised on examination with the ophthalmoscope.