In the other form of chronic oöphoritis the interstitial changes are most marked. There is a decided increase of the connective tissue, and a diminution of the parenchymatous or follicular structures. The ovary is hard and cirrhotic, and is of a lighter or paler color than normal; the visible ovarian follicles are few; the greater part of the ovary appears to be a mass of wrinkled connective tissue; in some cases the follicular structure is confined to but one-quarter of the ovary. The changes resemble and are similar to those that take place physiologically in the ovaries of old women (see Fig. 162). Between these two types of cystic and cirrhotic ovaries various forms, combinations of the two, may occur. The ovary upon one side may be cystic, upon the other cirrhotic. The _causes_ of chronic oöphoritis are various. The condition may persist after the subsidence of acute oöphoritis. It is usually secondary to salpingitis. There are very few cases of chronic salpingitis that are not accompanied by some form of oöphoritis. The disease may be chronic from the beginning. It may develop slowly from septic or gonorrheal infection from the uterus. It may result from subinvolution or prolapse of the ovary. It may result from immoderate sexual irritation, and from unnatural gratification of the sexual impulse. It seems probable also that chronic ovaritis may occur as the result of celibacy or sterility. The unceasing menstrual congestions of the virgin or the sterile woman, which, as has already been pointed out, seem to predispose the woman to fibroid changes in the uterus, seem likewise to develop the growth of connective tissue in the ovary. Virgins between the ages of thirty and forty often present hard cirrhotic ovaries with decided diminution of the follicular elements. The condition is often associated with a fibroid state of the uterus, this organ being indurated from interstitial fibroid deposit, or presenting one or more subperitoneal nodules. _Symptoms._--The most prominent symptom of chronic oöphoritis is pain. The disease is usually bilateral, and the pain affects both ovarian regions; it is, however, usually more marked upon the left side. The pain is increased by the erect position and by exercise, defecation, and coitus. Pain at defecation and coitus is most marked when ovarian prolapse accompanies the inflammation. The pain is increased at the menstrual period. It is most intense immediately before and at the beginning of the flow. If the bleeding is profuse, the pain is often relieved. Menorrhagia often accompanies chronic oöphoritis, and seems to occur chiefly with the cystic variety of the disease. As most cases of oöphoritis are accompanied by endometritis and salpingitis, it is difficult to determine how important a part in the production of the menorrhagia is played by the ovarian disease. Reflex pain in the region of one or both breasts, usually the left, is often complained of.