CONTRIBUTIONS TO THE HISTOGENESIS OF THE 
PAPILLARY CYSTOMATA OF THE OVARY. 
By J. Whitridge Williams, M. D., 
Assistant in Gynecology in the Johns Hopkins Hospital. 
(From the Pathological Laboratory of the Johns Hopkins University 
and Hospital.) 
[From The Johns Hopkins Hospital Bulletin, No. 18, December, 1891.] {From The Johns Hopkins Hospital Bulletin, No. 18, December, 1891.] 
CONTRIBUTIONS TO THE HISTOGENESIS OF THE 
PAPILLARY CYSTOMATA OF THE OVARY. 
By J. Whit ridge Williams, M. D., 
Assistant in Gynaecology in the Johns Hopkins Hospital. 
(From the Pathological Laboratory of the Johns UopJcins University 
and Hospital.') 
It is only within the last few years that the ovarian papillo- 
matous cystomata have been recognized as constituting a class of 
tumors perfectly distinct from the ordinary glandular cystomata; 
for previous to the year 1877 when Olshausen13 first demonstrated 
this fact the two forms of growths were considered as one, or at 
most subdivisions of the same class of tumors, and consequently 
as derived from the same source. This fact must be borne in 
mind in considering all the early work done upon this subject. 
Although the ordinary ovarian cystoma had been known for a 
great length of time as ovarian dropsy, it was not until 1829 that 
Hodgkin1 pointed out the existence of papillary growths upon the 
interior of the cyst. He ascribed their formation to pressure, and 
it will perhaps be interesting to quote his words describing the 
process. “ I have stated that it is at particular points on the in- 
terior surface of the superior cyst that clusters of inferior cysts 
take their origin. It sometimes happens that the number of cysts 
forming the clusters is so great in proportion to the space which 
they occupy that, like trees too thickly planted, they interfere 
with each other’s growth. Their development is more or less 
limited to an increase of dimension in length. Yet as their free 
extremities are allowed to diverge, we sometimes find the slender 
peduncle gradually dilating into a pyriform cyst. At other times 
the dilatation does not take place till near the extremity of the 
peduncle, and then produces a cyst more nearly resembling a 
grape or a currant. At other times no dilatation takes place, 
probably from the cavities having been wholly obliterated. The 
pedunculated cysts or the extreme of this variety in the form of 
filaments are either produced singly, but in the closest approxi- 
mation from a particular spot of the containing cyst, or they may be attached to it by a common pedicle from which the proper 
pedicle of each proceeds. These elongated structures sometimes 
become highly vascular and in the defect of an internal secretion 
contribute largely to that which occupies the sac into which they 
project.” We thus see that Hodgkin clearly directed attention to 
the papillary growths and regarded their origin as identical with 
that of the secondary cysts. 
Following Hodgkin there came a period during which it was 
thought that all forms of ovarian tumors were derived from the 
Graafian follicle; and this was the prevailing idea until 1848, when 
Virchow2 showed that the Graafian follicle produced only small 
cysts, which still contained the ovum, hydrops folliculi, and was 
incapable of giving rise to the large colloid tumors, for which 
other modes of origin must be sought. He believed that spaces 
lined by epithelial cells were constantly appearing in the stroma, 
from which the cysts were developed, and that they were there- 
fore of connective tissue origin and totally distinct from the cysts 
developed from the Graafian follicle. More or less similar views 
as to their origin from connective tissue were advanced by many, 
among whom were Foerster,3 Rokitansky4 and Frerichs.5 Once 
more the Graafian follicle theory was presented in 1864 by Klob6 
and Wilson Fox,7 both of whom considered that all forms of 
ovarian cysts could be derived from them. Fox described with 
great accuracy the gross and microscopic appearances of both the 
glandular and papillary cysts ; his ideas of their development 
were, however, erroneous; for having accurately described the 
gland-like structures found in the cyst wall, he considered that 
they were only apparent and were due to depressions formed 
between villi, which sprang from the wall of the cyst. He ex- 
plained the production of smaller cysts in the wall of the larger 
by supposing that the extremities of the villi came into apposition 
and then became adherent, and thus produced cavities beneath 
them, which might readily become larger and form small cysts. 
In several cases he saw structures, which he considered Graafian 
follicles, sending out diverticula, though in none of his cases was 
he able to demonstrate the presence of ova in them. 
Mayweg,8 four years later, attempted to reconcile the conflict- 
ing theories. Like Fox,7 he supposed that the great majority of 
ovarian cysts were derived from Graafian follicles, but that a cer- 
tain proportion had a connective tissue origin, as was believed by 
Virchow,2 Rokitansky4 and others. He not only considered the 
papillary cystoma to be a variety of the ordinary form ; but con- sidered the formation of papillae a constant and necessary occur- 
rence in the formation of the multilocular cystomata. He thought 
that as the papillae increased in size in a small cyst, they would 
be subjected to increased pressure by the contained liquid, and 
that in this way their tips would be forced into contact and, after 
they had lost their epithelium by attrition, become adherent and 
thus form secondary cysts by a method very similar to that de- 
scribed by Fox. 
In this connection, he gave a most interesting figure (Fig. 1, 
A, a, in Mayweg’s article), in which he depicted a small papillary 
growth arising from the wall of a Graafian follicle, in which the 
ovum was still present. 
During the year before and after Mayweg’s8 dissertation the 
papers, which prepared the way for Waldeyer’s wonderful article 
on the subject, were written. In the year 1867, Luecke and 
Klebs,9 after studying several tumors removed by Spiegelberg 
came to the conclusion that the growths were to be compared to 
the adenomata and it was impossible for them to be of connective 
tissue origin. In 1869, Boettcher10 foreshadowed Waldeyer’s12 
work, for in the more solid portions of a cystoma, he found “ an 
abundance of epithelial duct-like structures, which could be seen 
dilating into small cysts; ” these structures he compared to Pflue- 
ger’s ducts and stated that the cystomata might arise from these 
structures or from Graafian follicles or from both. He also con- 
sidered that papillomatous growths were formed by epithelial struc- 
tures growing down into the stroma, and not by the stroma push- 
ing forward the epithelium. 
Up to this time there was considered to be no particular differ- 
ence between the papillary and glandular tumors; indeed they 
were usually Considered merely as different phases of growth in 
the same tumor. As to their histogenesis, both forms alike were 
supposed to be derived from the Graafian follicle or ovarian stroma 
or both, according to the theory prevailing at the time. Though 
occasionally the proofs did not appear convincing, and the writers 
refused to commit themselves to any theory, as, Bauchet11 who 
said, “ Some authors suppose they arise from the Graafian follicle, 
others from the ovarian stroma. It may be so; but there is abso- 
lutely no anatomical ground for.the supposition.” To Waldeyer12 
is due the honor of having settled the question as to the histo- 
genesis of the ovarian cystomata and of placing the entire subject 
upon a sound basis. For in his epoch-making work, “Eirstock und Ei,” he gave a perfectly clear description of the anatomy and 
development of the ovary and thus laid the foundations for scien- 
tific study of its pathology ; and in his work on the epithelial 
ovarian tumors he clearly demonstrated that the cystomata were 
derived from Pflueger’s ducts, which were either remnants from 
foetal life or newly formed in the adult. According as the cys- 
tomata contained papillary ingrowths or not, he divided them into 
two classes: 
1. Cystoma proliferum glandulare. 2. Cystoma proliferum 
papillare. He did not, however, consider that there was any gen- 
eric difference between the two classes of growths ; the difference 
depending entirely upon the relative rapidity of growth of the 
component parts of the tumor. If the epithelium took the more 
active part in the growth, an adenomatous tissue resulted and a 
glandular cystoma was produced; if, on the other hand, the con- 
nective tissue was the actively growing part, it pushed forward the 
epithelium and produced papillary ingrowths from the cyst wall 
and gave rise to a papillary cystoma. 
This was the state of affairs until 1877, when Olshausen13 showed 
that the papillary cystoma differed both anatomically and clinic- 
ally from the glandular form and should therefore be considered 
as constituting a class of growths totally independent from them. 
He came to this conclusion by considering the following facts: 
“Anatomically these tumors differ from the cystomata in that 
they are usually only of moderate size and never attain the huge 
proportions which are frequently observed in the glandular 
cystomata. They contain in their interior numerous papillary, 
cauliflower-like tumors, which often entirely fill the lumen of the 
smaller cysts and break through their walls, and not infrequently 
through the walls of the principal cyst. After breaking through 
the cyst wall, they usually spread to the neighboring organs and 
grow particularly upon the peritoneum. The interior of the cysts 
is usually lined by ciliated epithelium. The number of cysts 
making up the tumor is quite limited. 
The growths are usually bilateral and in three-fourths of the 
cases develop extra-peritoneally, usually between the folds of the 
broad ligament; and lastly the fluid contents are characterized 
by a lack of colloid constituents. Clinically, these tumors grow 
far more slowly and soon give rise to pressure symptoms, owing 
to the fact that they are developed extra saccum peritonei. They 
are frequently accompanied by ascites, which is often of consider- able amount and recurs rapidly after tapping. And lastly they form 
metastases, or, more properly speaking, grow by dissemination of 
the papillomata over the peritoneum and invade the other organs.” 
From the fact that they grew within the folds of the broad 
ligament and were lined by ciliated epithelium, Olshausen con- 
cluded that their development was in some way connected 
with the parovarium, which was known to contain ciliated epi- 
thelium and which in some cases penetrate the hilum of the ovary 
as the so called medullary cords (Markstraenge) of Koelliker.14 
This view appeared quite plausible and soon gained general ac- 
ceptance, and, in spite of the fact that it has since been repudiated 
by its originator, is still held by many writers on the subject. 
Olshausen’s work was soon followed by an article by Fischel,15 
who accepted Koelliker’s14 theory of the development of the ovary 
(that is, that only the ova are developed from the germ epithelium, 
and that the membrana granulosa is derived from strings of cells, 
of Wolffian body origin, which penetrate the hilum of the ovary), 
and stated “ that we must consider the ciliated ovarian cystomata 
to be derived from parovarial elements, particularly from the 
granulosa cells and not from the parovarium or organ of Rosen- 
mueller as such.” He adduced no evidence to prove this point, 
and from the description of his specimen it is not at all clear that 
he had to do with an ovarian tumor at all, but rather with a 
papillary cyst developing in the broad ligament; for he stated 
that on the upper part of the cyst the flattened out ovary was 
found, and that the tumor developed from the hilum. And accord- 
ing to his description it might have arisen just as well from the 
parovarium. The only point that he brought forward to prove 
the truth of Koelliker’s hypothesis was that here and there in his 
specimens he found ova around which he could find no trace of 
a membrana granulosa, and considered that they lacked a mem- 
brana granulosa because the ingrowths from the Wolffian body 
had not reached up to them. Coblentz,16 the same year, described 
two cases of papillary cysts of the ovary ; one of which was the 
size of a goose egg and was covered with papillary growths; it 
contained small cysts, from whose walls papillary projections 
arose. On section, he found the ovary traversed in all directions 
by bands of epithelial cells, arranged more or less radially to the 
hilum and resembling Pflueger’s ducts in appearance. Some of 
these structures communicated directly with the surface of the 
ovary but never contained ova. These bands of cells could be seen dilating into small cysts, which were lined by ciliated epithe- 
lium and contained papillary ingrowths. 
A similar condition was noted in a small superficial papilloma 
of the ovary in another case. These structures he thought were 
of Wolffian body origin and corresponded to Koelliker’s “Mark- 
straenge.” From his elaborate study of the subject, he concluded 
“ that the lining of Pflueger’s ducts, as well as Koelliker’s “Mark- 
straenge,” is capable of functioning as a real mucous membrane, 
since they are both descendants of such structures; and that the 
starting point of the glandular cystomata is from Pflueger’s ducts 
and that of the papillary ciliated cystomata from Koelliker’s 
“ Markstraenge,” at a time before they are differentiated, the one 
into ova and the other into granulosa cells. 
The work of Fischel15 was confirmed by Stryczek17 in every 
particular, and he stated that growths developed from parovarial 
elements were far more frequent than was usually supposed. 
The theory of development from remains of the Wolffian body 
has appeared fascinating to English and American writers on the 
subject, and even now, when most others have forsaken the theory, 
they still cling to it. 
Thus, Doran18 still accepts the theory in its widest possible 
sense. For he regarded even very small papillary cysts in the 
zona parenchymatosa of the ovary and far removed from the hilum 
(the seat of the remains of the Wolffian body), as of Wolffian 
body and origin, and stated that “ they must have originated from 
Wolffian elements in the stroma of the parenchyma of the ovary.” 
And in speaking of a case of papillary broad ligament cyst, he 
said “ the absence of any trace of ovary in this specimen of Mr. 
Thornton is strong evidence in favor of the supposition that the 
cyst arose in the hilus of the ovary and forced its way into the 
broad ligament, and on the other hand absorbed or destroyed the 
tissue of the parenchyma of the ovary.” In his work,19 “ Tumors 
of the ovary, fallopian tubes and broad ligaments,” he recorded a 
most interesting case, which lie observed in the ovary of a seven 
months’ foetus. It contained several small cysts 1-16 to 1-12 of 
an inch in diameter, which were lined by ciliated epithelium and 
filled by papillary growths ; and in spite of the fact that the ovary 
contained no ova, while the other ovary contained them in large 
quantities, he concluded that they were also derived from Wolffian 
body elements. The latest American writer on the subject is Howell,20 in Mann’s 
System of Gynaecology (1889), who accepted the same views as 
Doran, and stated “that other views as to their development are 
far from satisfactory.” 
We will now turn from these theories, which at present are 
considered by most original workers on the subject to be unfounded, 
and consider those which offer simpler and more rational expla- 
nations of the development of these growths. 
We will first consider the theories which suppose the germinal 
epithelium of the ovary to be the source of origin for the papillo- 
matous growths. The first important theory advanced in this 
direction was that of Marchand,21 in 1878, who, in an able work 
on the subject, was able to substantiate Olshausen’s statement as 
to the distinction between the glandular and papillary cystomata, 
and stated that the presence or absence of cilia in the growths 
made no difference in this regard. He also stated that they were 
developed from several points of origin, basing the statement upon 
a case of Olshausen’s, in which the lateral half of an ovary, en- 
larged to the size of a walnut, was studded with small cysts, vary- 
ing from a pin’s point to a cherry in size, and which were lined 
by ciliated epithelium and were filled by papillary growths. He 
repudiated the theory that they were developed from the Wolffian 
body, and directed attention to the near relationship existing be- 
tween the epithelium of the tube and that covering the surface of 
the ovary, and pointed out that at an early period of foetal life 
they are one and the same surface, and in the adult are only sep- 
arated from one another by a small band of tissue at the fimbria 
ovarica. His theory was that in some cases the dividing line 
between the two forms of epithelium, instead of remaining at the 
end of the fimbria ovarica, might extend over the lateral portion 
of the ovary, and thus cover it with ciliated epithelium, from 
which ciliated processes analogous to Pflueger’s ducts might ex- 
tend into the stroma and possibly in some cases form Graafian 
follicles lined by ciliated epithelium, from which ciliated cysts 
might readily arise. Owing to the near relationship of such 
structures to the epithelium of the tube with its peculiar arbores- 
cent structure, it was not difficult to conceive that these cysts 
should have a tendency to form papillary ingrowths. 
The same year, a most interesting observation of De Sinety and 
Malassez22 placed the entire subject in a new light. For, on 
microscopic sections of what appeared to be an ordinary small cystic ovary, with dilated follicles in both its superficial and 
deeper portions, they were surprised to discover that the cysts 
were not dilated follicles at all, but were lined by a single layer 
of columnar epithelium, which at times was ciliated. Epithelial 
tubes running through the ovary in various directions were also 
seen. These structures were lined by columnar epithelium, which 
was also ciliated ; and some of them were seen to open directly 
upon the surface of the ovary, and their epithelial lining to be 
continuous with the germinal epithelium of the ovary ; while 
others were seen to communicate with smaller cysts, which were 
evidently formed by dilation of the above mentioned epithelial 
tubes. They observed this condition in two cases, and considered 
the structures to be analogous to Pflueger’s ducts, and to have 
been formed in adult life. These structures they naturally con- 
sidered to be the source of the papillary ciliated growths, and they 
certainly offered a more rational explanation of their production 
than the Wolffian body theory. They believed that the frequent 
occurrence of these cysts near the hilum was due to the increased 
vascularity of that part of the ovary : “ note also that the most 
frequent seat for vegetations is in the neighborhood of the pedicle, 
as if the more vascular portions of the ovary were more propi- 
tious for pathological development.” 
The observations of De Sinety and Malassez were soon confirmed, 
for the next year Flaischlen23 published similar cases. Both of his 
observations were made in cases of papillary cystomata, and in 
each he found epithelial tubes, lined by columnar and ciliated 
epithelium, penetrating in all directions the intact portions of the 
ovary, which presented an appearance similar to that of the Pflue- 
ger’s ducts, as described by Waldeyer12 in the foetal ovary. These 
structures could be seen dilating into cysts, lined by columnar 
and ciliated epithelium, which sometimes contained papillary 
growths; and occasionally a direct communication between these 
structures and the superficial epithelium of the ovary could be 
demonstrated. The following year he was able to demonstrate a 
similar condition in another papillary cystoma, in which the sur- 
face of the intact portion of the ovary was covered by ciliated 
epithelium, between which and the epithelial tubes and the small 
cysts a distinct connection could be traced. This was certainly 
conclusive proof, and no one could possibly object to his conclu- 
sions :24 “ that the papillary cystomata arise from the ovary and 
not from the parovarium, and that they take their origin from tubes lined by columnar and ciliated epithelium, which originated 
from the germinal epithelium.” 
Indeed the observations of De Sinety and Malassez and Flaischlen 
were so convincing, that Olshausen,25 in the second edition of his 
work “ Die Krankheiten der Ovarien,” in 1886, totally repudiated 
his original idea as to their development from the W olffian body, and 
stated that he could take no exception to Flaischlen’s statements. 
The latest work in this connection was by Frommel26 (1890), who 
described a case of superficial papilloma of the ovary, which was 
clearly derived from the germinal epithelium. He also thought 
that the usual form of papillary cystoma might develop from the 
germ epithelium or from the granulosa cells of the Graafian fol- 
licle. He arrived at the latter conclusion purely by a logical 
process and had no preparations upon which to base his state- 
ments. He argued thus: “We know by Waldeyer’s researches 
that the granulosa cells of the Graafian follicle are derived from 
the germinal epithelium; we also know from Flaischlen’s obser- 
vations that, under certain circumstances, the germinal epithelium 
may become ciliated, and investigations upon certain of the lower 
animals have shown that in some species both the germinal epi- 
thelium and the granulosa cells are ciliated; such being the case, 
why cannot the granulosa cells in man become ciliated under cer- 
tain circumstances of which we are as yet ignorant? And if 
so, why may not papillary cystomata sometimes arise from the 
Graafian follicle ? ” 
According to him, the superficial papilloma is more liable to be 
developed when a few broad ingrowths of germinal epithelium 
occur at some distance apart from each other; while, if a number 
of ingrowths take place from a comparatively small area, the 
papillary cystoma is more apt to be formed. 
The germinal epithelium theory received a qualified support 
from Steffeck,27 who thought that it might play a part in the 
development in some cases. 
Somewhat allied to the views just mentioned, is the theory of 
Nagel,38 who pointed out the fact that the germinal epithelium 
is frequently preserved under peritoneal adhesions about the 
ovary, and that the irritation caused by the inflammatory changes 
might lead to a proliferation of the germinal epithelium, with the 
formation of pseudo-Pflueger’s ducts and the development from 
them of all forms of ovarian tumors. The proof adduced in sup- 
port of these observations is not at all convincing. In this connection we might also refer to the case of superficial 
papilloma of the ovary, reported by Gusserow and Eberth,29 whose 
development they stated was dependent upon inflammatory changes 
and probably upon an oophoritis. But in view of what has been 
said above, such a theory is absolutely without foundation. 
Having considered all other possible sources of development, 
we will now consider those theories which take the Graafian folli- 
cle as the point of development for these growths. As I pointed 
out in the first part of the article, this was one of the earliest 
theories concerning the origin of all forms of ovarian tumors, and 
one which always received more or less support, except for a short 
time after the appearance of the work of Waldeyer and Olshausen, 
when it was almost completely lost sight of. In this connection 
it is only necessary to recall the fact that Fox,7 Klob,6 Mayweg,8 
Spiegelberg80 and Boettcher10 accepted the Graafian follicle as the 
origin of most, if not all, cysts of the ovary; and that Mayweg 
and Fox considered the formation of papillary processes from the 
wall of the follicle to be the first step toward the formation of 
multilocular cystomata. The idea that ciliated papillary cysts 
might be derived from ciliated Graafian follicles was advanced by 
Marchand21 and Frommel,26 from purely theoretical considera- 
tions ; but they had no specimens to prove that the Graafian fol- 
licle in man could ever become ciliated, and much less give rise 
to papillary growths. 
Another recent believer in the Graafian follicle origin of the 
papillomata, was Koeberle;31 but, like Marchand and Frommel, 
he possessed no accurate observations upon which to base his 
statements. 
The most recent work on the subject has tended, however, to 
bear out the theoretical deductions of Marchand and Frommel, as 
will be seen from the consideration of the recent work of Von 
Velits and Steffeck. 
Von Velits,32 in 1889, wrote a most interesting article on the 
histology and genesis of the ciliated papillary cystomata, basing 
his work upon the consideration of nine cases. In two cases, in 
relatively intact portions of the ovary, he found small cysts, ap- 
parently dilated follicles, which were lined by a single layer of 
cylindrical epithelium, which in some cases was ciliated ; and in 
one instance he was fortunate enough to find an ovum in one of 
them, which abundantly proved that the theories of Marchand20 
and Frommel26 were correct, and that it was possible for the human 
Graafian follicle to become ciliated. As none of these small cysts communicated with the germinal 
epithelium, he considered them ail Graafian follicles, and stated 
that it was from them that the papillomata were developed. In 
none of them, however, was he able to demonstrate papillary 
growths, and consequently absolute proof of the correctness of his 
assertions was still lacking. He, however, considered the presence 
of psammoma bodies to be absolutely pathognomonic of ciliated 
papillary cystomata, and, as he found them in the neighborhood 
of the ciliated Graafian follicles, he considered his position posi- 
tively proved. 
The very latest work published on the subject of the ovarian 
tumors was by Steffeck,27 1890, who once more reverted to the 
old view that the glandular cystomata might arise from the 
Graafian follicle. He came to this conclusion on finding Graa- 
fian follicles, which still contained ova, undergoing proliferative 
changes and sending out offshoots into the surrounding tissue, 
from which daughter cysts were developed. He sustained his 
position by drawings, which, if correct, prove his point. He did 
not consider the follicle the only source of origin, but stated that 
they might be developed equally as well from Pflueger’s ducts; 
and that if either of these structures became ciliated, they might 
give rise to the ciliated papillary cystoma. He stated the case as 
follows: “ Primarily, neither the germinal epithelium nor fol- 
licular epithelium is ciliated ; but at any time either epithelium 
may be converted into high cylindrical epithelium. If, now, 
under certain circumstances, an ‘ irritation ’ be given, which will 
cause cylindrical epithelium to become ciliated, nothing could be 
more natural than for this ‘ irritation ’ to affect the cylindrical 
follicular epithelium, as well as the cylindrical germinal epithelium; 
and consequently both forms of epithelium could take part in the 
production of the ciliated papillary cystomata.” 
In the preceding pages I have endeavored to trace the history 
of the several theories advanced in connection with the develop- 
ment of these growths; and from their variety, it will readily be 
seen that a definite conclusion has not yet been reached. Indeed, 
the number of theories advanced has been limited only by the 
number of structures entering into the composition of the ovary. 
Thus, before the time of Waldeyer, we had the connective tissue 
and Graafian follicle theories ; and after the work of Pflueger 
and Waldeyer added the Pflueger’s ducts and germinal epithe- 
lium to the component parts of the ovary, the limits of possibility were extended, and we had these structures utilized as sources of 
origin. When to this we add Noeggerath’s33 theory of the devel- 
opment of the cystomata from the blood-vessels, we see that every 
tissue entering into the formation of the ovary has been laid hold 
upon and made the basis of one or more theories. As if these 
were not theories enough, others have sought in the parovarium 
or Wolffian body the possible source of these growths. 
I now desire to record several interesting cases, which I hope 
will throw more light upon the subject of the histogenesis of the 
papillary ovarian cystomata and enable me to show that several 
of the theories, instead of contradicting one another, are based 
upon accurate observations and are entitled to consideration. 
Case I.—“Adherent tubes and ovaries,” peri-salpingo-oophoritis, 
small papillary cyst in mesosalpinx, and ciliated structures of tubal 
origin in the ovarian stroma. 
Mrs. V., March 26, 1890, both tubes and ovaries removed by 
Dr. Kelly for chronic salpingo-oophoritis; recovery. The struc- 
tures removed presented the usual appearance in such cases; both 
tubes and ovaries being covered by thin adhesions and more or 
less bound together. The ovaries presented numerous dropsical 
follicles and the tubes a moderate degree of catarrhal salpingitis. 
The left tube and ovary were adherent, particularly at their 
lateral ends, where the fimbriated extremity of the tube was 
densely adherent to the ovary. Just at this point, apparently 
on the surface of the ovary, was a small cyst 5 mm. in diameter, 
with clear contents; which was apparently a dilated follicle. 
On cutting sections through this cyst and the adjoining por- 
tions of the tube and ovary, one obtained the appearance repre- 
sented in Fig. 1. It was then seen that the cyst did not arise 
from the ovary at all, but was situated in the mesosalpinx, sur- 
rounded by a thin layer of non-striated longitudinal muscular 
fibres. From the inner wall of the cyst arose several small papil- 
lary projections, three of which are represented in the drawing. 
All of them possessed a framework composed of spindle-shaped 
connective tissue cells, are well supplied with blood-vessels, and 
are covered with a single layer of high columnar ciliated epithe- 
lium, with large oval nuclei. In the lower portion of the figure 
is seen ovarian tissue, which contains primitive Graafian follicles 
(Fig. 1, a). The ovary and mesosalpinx were densely adherent for the 
greater part; but in a part of their extent, where they were not 
adherent, a double line of epithelium was seen, which varied from 
flat to columnar in shape, and represented the original germinal 
epithelium and the peritoneal surface of the mesosalpinx {Fig. 1, 
b). At the lower left hand corner of the drawing {Fig. 1, c), is 
seen a portion of the fimbriated extremity of the tube, which is 
densely adherent to the ovary and covered by high columnar 
ciliated epithelium. The most interesting feature of the specimen 
and the one to which I desire to direct particular attention, is the 
occurrence of larger or smaller spaces, lined by high columnar 
ciliated epithelium and imbedded in the stroma of the ovary just 
adjacent to the fimbriated extremity {Fig. 1, d). These struc- 
tures are quite numerous and vary considerably in size, from very 
small circular structures to larger structures with an irregular 
outline. They are all lined by high columnar ciliated epithelium, 
similar to that seen on the fimbriated end of the tube, and appa- 
rently represent sections made through epithelial ducts in various 
directions. Their origin was not, at first sight, apparent; but on 
cutting serial sections it could be seen that several of them were 
directly continuous with the epithelium covering the adherent 
fimbriated extremity of the tube, from which they were clearly 
outgrowths. 
As represented in the drawing {Fig. 1, d), they were not con- 
fined to the stroma of the ovary, but were also found between the 
muscular layers of the mesosalpinx. Whether the small cyst 
above referred to was derived from such a structure I am unable 
to state absolutely ; for I have seen similar cysts in the mesosal- 
pinx in cases in which there was no suspicion of such epithelial 
growths as those mentioned. This point, however, is a matter of 
indifference; for whatever may be the origin of the cyst in the 
mesosalpinx, there can be no doubt as to the presence of these 
epithelial structures in the ovary and their origin from the tubal 
epithelium. This observation, as far as I am able to discover, is 
unique, and tends in a limited way to substantiate Marchand’s21 
theory of the origin of papillary cysts from ingrowths of ciliated 
epithelium, which were derived from that of the tube by Nature’s 
failure to establish at the end of the fimbria ovarica the usual 
division line between the non-ciliated germinal epithelium and the 
ciliated epithelium of the tube. The difference between Marchand’s theory and my observation 
is, that in his case, the presence of ciliated epithelium on the 
ovary was a congenital defect; while in my case it occurred in 
adult life and probably was the result of disease. 
I will refrain from any theoretical attempts to explain the 
cause of this proliferation of the tubal epithelium, and will be 
content with the mere statement of the fact. 
In this case we have structures lined by columnar ciliated epi- 
thelium, of tubal origin in the stroma of the ovary ; and we might 
readily conceive that in some instances papillary ciliated cysts 
might develop from them. This mode of origin is closely related 
to that supposed by Marchand and clearly indicates that his 
theory is not beyond the limits of possibility. 
Case II.—Superficial Papilloma of the Ovary; Hydrosalpinx, 
with peculiar cystic formation in the tube, small corpus luteum cyst 
and adhesions about tube and ovary. 
Mrs. H., laparotomy by Dr. Kelly, October 15, 1890. Both 
ovaries and tubes removed; recovery. Description of specimens: 
Right side—Tube measures 6 cm. in length, 0.3 at narrowest part 
and 0.9 cm. at thickest part, fimbriated extremity free ; the tube 
appears normal. Ovary measures 4, 3, T? cin. in its several 
diameters; is covered by thin adhesions, with many cicatrices on 
its surface. On section, one sees at its median extremity, near its 
upper border, a corpus luteum cyst 1 cm. in diameter and adjoin- 
ing it a dilated follicle. On the superior surface of the tube are 
numerous small clear cysts, § to 2 mm. in diameter, and below 
the tube the enlarged parovarium. Left side—The tube wTas rep- 
resented by a hydrosalpinx, which was ruptured during the opera- 
tion. Its fimbriated end was closed and its uterine end firmly 
adherent to the ovary. 
Left ovary measures 4, 2, 1.5 cm. in its various diameters; and 
its surface covered with numerous adhesions and cicatrices. At 
its lateral end and adherent to the end of the tube is a mass of 
small cysts 1.5 cm. in diameter, apparently a beginning cystoma. 
On the superior surface of the ovary, about its middle, is a papil- 
lary mushroom-like mass, triangular in shape, and 1 cm. in diam- 
eter and 3 mm. thick, which arises from the ovary by a pedicle 
about 2 mm. long and the same in diameter. The surface of the 
mass is marked by numerous fine lines, indicating depressions into 
its interior. Sections through the apparently cystic formation at the end of 
the ovary show that it consists of a twisted mass of epithelial 
structures, which is connected with the lumen of the tube. The tube 
and ovary were adherent, and between them and lining the interior 
of some of the adhesions is well-preserved germinal epithelium. 
Remains of the Wolffian body were seen in the mesosalpinx. 
The point of interest for us in this very interesting specimen, is 
the superficial papilloma of the ovary, which, as far as I can 
learn, is the ninth case on record16,21 •26,29,34’36,86. Sections through 
the papillomatous mass and the subjacent portions of the ovary 
{Fig. 2) reveal most interesting conditions. The growth had a 
distinctly mushroom-like shape and was composed principally of 
spindle-shaped cells, exactly similar to those found in the ovary, 
with which they were continuous through the pedicle; its blood 
supply was very scanty. Its most interesting feature was that it 
was penetrated in all directions by epithelial structures, varying 
in shape from simple cylindrical canals to broad, flat depressions, 
some of which extended through almost its entire thickness, and 
all of which were lined by a single layer of ciliated cylindrical 
epithelium {Fig. 2, a). All these epithelial structures could 
readily be traced to the surface of the growth, where the broad, 
flat depressions were seen to correspond to the lines mentioned in 
the macroscopic description. The ciliated epithelium lining them 
extended up to the surface of the papilloma, from which the epi- 
thelium unfortunately had been rubbed off, but which I suppose 
was similar to and continuous with the epithelial lining of these 
structures. 
The pedicle presented the same structure as the growth itself, 
and was perforated by numerous epithelial structures, lined by 
ciliated epithelium. It also contained a typical psammoma body 
{Fig. 2, b). The subjacent ovarian tissue contained no ova, but 
was perforated in several places by epithelial structures similar to 
those found in the papillomatous mass {Fig. 2, c). It also con- 
tained psammoma bodies {Fig. 2, d). 
The germinal epithelium was absent from the greater part of 
the surface of the ovary and was only preserved in one or two 
protected portions {Fig. 2, e), when it was found to be represented 
by a single layer of tolerably high, columnar, ciliated epithelial 
cells, which were of the same appearance as those lining the epi- 
thelial structures in the papillomatous mass and the ovary. This 
condition of the germinal epithelium present, indicated that the entire epithelial covering of the ovary had been of the same 
character, and made it most probable that the surface of the 
papilloma had also been covered by ciliated epithelium. 
The ciliated condition of the germinal epithelium is most inter- 
esting, and is similar to that reported by Flaischlen in another 
case. It also proves conclusively that under some circumstances 
the germinal epithelium may become ciliated, without supposing 
any connection to exist between it and the epithelium of the tube, 
as Marchand did. The appearance of the growth and the ciliated 
condition of the epithelium is conclusive proof that it wras in 
some way formed by ingrowths of the germinal epithelium into 
the stroma of the ovary; and most probably, as described by 
Fi’ommel26 in a similar case, by broad, flat processes of epithelial 
cells extending down into the stroma of the ovary and almost 
cutting out a portion of it, which, as it grew, was raised above the 
surface of the germinal epithelium and thus made to appear as 
a superficial growth. Moreover, the presence of spaces lined by 
ciliated epithelium in the stroma of the ovary is analogous to 
those described by De Sinety and Malassez,22 and Flaischlen,24 and 
it is most probable that papillary growths would have sprung 
from their walls as they increased in size, and thus have given rise 
to a papillary cystoma. 
This observation cannot be considered ambiguous in any sense, 
and the only possible conclusion which can be drawn from it is, 
that under certain circumstances the germinal epithelium may 
become ciliated and give rise to papillary growths, of both varie- 
ties, as stated by De Sinety and Malassez,22 Flaischlen,24 and 
Frommel.26 
This is certainly a rational explanation for many cases, and it 
is more than probable that the epithelial structures described by 
Coblentz16 in several of his cases, were derived from the germinal 
epithelium instead of the Wolffian body. 
Case III.—Beginning Papilloma of the Ovary; acute purulent 
salpingitis. 
K. K., aged 27 years; laparotomy, November 1, 1890, by Dr. 
Kelly; recovery. Ovaries and tubes of both sides removed. 
Description of specimens: Left side—Tube measures 10 cm. in 
length, 0.5 at uterine and 1-5 cm. at fimbriated end ; fimbriated 
extremity free. The tube is filled with bloody pus, and its outer I. 
7$ SZ 
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7tf-2T. half is of a dark red color, owing to the intense congestion. The 
mesosalpinx is apparently normal. The ovary is very flattened 
out and measures 5, 3 and } cm. in its various diameters; on its 
surface are numerous thin adhesions, and on section it is soft and 
presents numerous follicles with haemorrhagic walls. Microscopic 
sections of the tube show that it is intensely inflamed, with its 
vessels engorged and its lumen filled with pus. Its outer half is 
so intensely congested that the folds of the mucous membrane are 
almost entirely filled with blood. On its peritoneal surface is 
seen a fresh fibrinous exudate. Cultures from the pus demon- 
strate the presence of numerous colonies of the staphylococcus 
aureus. Sections of the left ovary show numerous ripe and dila- 
ted follicles, with haemorrhage into them and also into the stroma. 
Right side—The tube measures 6 cm. in length, 0.4 at uterine and 
1.5 cm. at the fimbriated extremity; the fimbriated extremity is 
occluded and somewhat adherent to ovary. 
The ovary is small, measuring 3, 2 and li cm. in its various 
diameters; its surface presents numerous cicatrices and is cov- 
ered by thin adhesions. A longitudinal section through the ovary 
shows the portion about the hilum filled with large thick-walled 
vessels; while the zona parenchymatosa contains many dropsical 
follicles, many of which have very irregular outlines. The most 
interesting condition for us in this specimen is a Graafian follicle, 
which presents marked evidence of beginning papillary formation. 
This is a dilated follicle about 4 mm. in diameter, and situated 
near the superior surface of the ovary, and filled with clear liquid. 
On section (Fig. 3), it presented the typical appearance of a 
dilated follicle, having a typical membrana granulosa, which was 
composed of several layers of cuboidal epithelial cells, with large 
clear nuclei and surrounded by the spindle cells of the ovarian 
stroma. 
From one point of its inner wall a club-shaped process about 1 
mm. long projected into its interior (Fig. 3, a). This process was 
covered by the many layered membrana granulosa cells, and its 
framework composed of spindle cells and blood vessels, which 
were continuous with those of the surrounding stroma. A short 
distance from this, a similar but smaller process was also noted 
(Fig. 3, b), and at a third point, a slight elevation indicated the 
beginning of a similar process (Fig. 3, c). 
All of these structures were covered by several layers of epithe- 
lial cells, similar to and continuous with those lining the rest of the follicle, and their framework was composed of the spindle- 
shaped stroma cells, containing vessels. These projections were 
evidently produced by ingrowths of the ovarian stroma toward 
the interior of the follicle, which simply pushed before them the 
membrana granulosa, which still covered them. 
I consider that this specimen represents the very earliest stage 
in the development of the ovarian papillomata and clearly de- 
monstrates that they may be developed from the Graafian follicle. 
In spite of the fact that I was unable to demonstrate an ovum 
within the follicle, I believe that there can be no question as to its 
identity. For it is only necessary to look at the epithelium lining 
it to recognize in it the typical membrana granulosa; and a com- 
parison of this follicle with others which still contain ova places 
the question beyond all doubt. 
The specimen just described does not, however, place the histo- 
genesis of the papillomata beyond all doubt; for it would be im- 
possible to state a priori that these simple outgrowths could give 
rise to the complicated forms of the developed growth. But my 
next observation will demonstrate that this is the case and will 
thoroughly establish this mode of origin for the papillomata. 
Case IV.—Peri-salpingo-odphoritis, hydrosalpinx and Begin- 
ning Papilloma of the Ovary. 
E. R., both tubes and ovaries removed by Dr. Kelly, October 
2, 1890. Description of specimens : Right side—The tube and 
ovary are represented by a ragged mass of tissue, in which it is 
impossible to distinguish the component parts. Left side—The 
tube is converted into a hydrosalpinx, which measures 10 cm. in 
length, 0.5 at the thinnest, and 2.5 cm. at the thickest part. It 
is wound around the ovary and filled with clear, transparent 
liquid. The fimbriated end is occluded and its site indicated by 
a stellate arrangement of depressed lines; its surface is smooth 
and glistening with a few thin adhesions. Scrapings from its 
walls show that it was lined by ciliated cylindrical epithelium, 
the cilia having been seen in motion. Cultures from its contents 
show no growth of micro-organisms. 
The left ovary measures 4, 2.5, and 1.5 cm. in its various 
diameters. Many adhesions bind it firmly to the tube. At its 
distal end is a freshly-ruptured corpus luteurn ; it contains numer- 
ous dilated follicles; one particularly, situated on its anterior sur- face near its lateral end, is quite large, measuring 7 mm. in 
diameter and filled with clear fluid. Sections through this follicle 
reveal a most interesting condition, for we find a papillomatous 
mass 3 mm. in diameter, growing from its internal wall. This 
mass (Fig. 4, a) presents the typical arborescent appearance of a 
well-developed papillary growth, and a single glance is sufficient 
to demonstrate its relationship to the ordinary papillomata of the 
ovary. It is seen to spring from the wall of the follicle by a well- 
marked pedicle, through which its stroma becomes continuous 
with that of the rest of the ovary, as is well represented in the 
drawing. Most of its framework is composed of tissues identical 
with that of the ovarian stroma and very rich in spindle cells; 
though in some of its more outlying portions the tissue appears 
almost hyaline and contains very few cells (Fig. 4, b). The 
growth is covered by a single layer of polymorphous epithelial 
cells, most of which are cylindrical in shape and contain large 
oval nuclei, which occupy a great part of the cell and lie equidis- 
tant from its margins. 
The lining of the follicle itself is also very interesting, for it 
presents all possible forms of epithelium and clearly demonstrates 
that one form may readily change to another; for in this case we 
find the typical cuboidal membrane granulosa cells arranged in 
several layers; then well-marked cylindrical and, lastly, flattened 
epithelial cells arranged in a single layer and following one 
another in close succession. The follicle is surrounded by typical 
ovarian stroma. Beside the well-marked papillary growth, we 
have indications at another point (Fig. 4, c) of more rudimentary 
papillary formation, similar to that noted in Case III. On none of 
the epithelial cells, either those covering the growth or those lin- 
ing the follicle, was I able to demonstrate cilia. Their absence, 
however, is completely a matter of indifference, as I will show 
later. 
That we have to do with a Graafian follicle in this case is 
clearly proved by the fact that in several places we found its in- 
terior lined by the typical membrana granulosa cells, in spite of 
the fact that I was unable to demonstrate an ovum within it. 
I believe that no one who has carefully considered the facts 
brought forward in the last two cases, can have any reasonable 
doubt that papillary cysts of the ovary may in some cases arise 
from the Graafian follicle; and it is only necessary for a similar 
change to take place in several Graafian follicles in order to pro- duce a typical multilocular papillary cystoma. As both of these 
cases occurred on or near the surface of the ovary, and as neither 
of them showed any signs of possessing cilia, I am aware that the 
statement, that papillary cysts of the ovary may be derived from 
the Graafian follicle, is open to two objections, and that it might 
be said that such a mode of origin is perhaps applicable to the 
simple non-ciliated papillary cystomata, which are not supposed 
to invade the folds of the broad ligament, but that it cannot pos- 
sibly apply to those growths which lie within the folds of the 
broad ligament and are lined by ciliated epithelium. These ob- 
jections are well taken, and I shall now proceed to prove that 
they are unfounded and that the ciliated intra-ligamentous papil- 
lary cystomata can also be derived from the Graafian follicle. 
In order to prove the correctness of this assertion, it will be neces- 
sary to prove that the Graafian follicle may under certain cir- 
cumstances become lined by ciliated epithelium and grow between 
the folds of the broad ligament. And I am happy to say that I am 
able to prove both of these statements by my own observations. 
In the first place I will consider the possibility of growths de- 
rived from a Graffian follicle growing within the folds of the 
broad ligament. In this connection we must be far more careful 
in distinguishing between intra-ligamentous cysts, which are de- 
veloped from the ovary, and those of other origin. Heretofore, 
sufficient stress has not been laid upon this point, and I am sure 
that many cases described as intra-ligamentous ovarian cysts were 
not ovarian at all, but were derived from the parovarium and 
affected the ovary merely by pressure, as in the cases of Doran 
and Fischel, which I referred to in considering their work. For 
in several cases I have seen perfectly well marked papillary cysts 
developed within the folds of the broad ligament, which had abso- 
lutely no connection with the ovary, and which, when they had 
attained a greater size, might have readily flattened it out or 
caused it to atrophy. 
I also desire to call attention to the fact that Olshausen’s13,15 
statement, that the great majority of papillary ovarian cysts are 
developed within the folds of the broad ligaments, is greatly ex- 
aggerated and will sustain my position by Doran’s figures. He 
found 9 cases developed within the folds of the broad ligament 
and 4 cases without it, which possessed regularly formed pedicles. 
Now, when we take into account the fact that he certainly reck- 
oned among his intra-ligamentous ovarian tumors, several of other origin, it will be evident that considerably less than one-half of 
his cases were developed within the broad ligament. This accords 
with my own experience, for I have lately seen three cases, none 
of which were intra-ligamentous. 
Having thus shown that the intra-ligamentous development of 
these growths is less common than is generally supposed, it now 
becomes necessary to ascertain whether it is possible for a cyst 
developed from a Graafian follicle to grow within the folds of the 
broad ligament. Theoretically, there is no possible objection to 
an enlarged Graafian follicle, situated near the hilum, growing 
down in the direction of least resistance between the layers of the 
broad ligament. But, practically, as far as I can learn, there is 
no undoubted case on record in which such a mode of growth has 
been observed. 
I have been fortunate enough to have observed such a case, 
which I will record in this connection. 
Case Y.—Miliary Tuberculosis of the Fallopian Tube; Intra- 
ligamentous Hydrops Follieuli. 
Mrs. C., both ovaries and tubes removed by Dr. Kelly, Febru- 
ary 21,1891; recovery. Description of specimens: Eight side— 
was so mutilated that examination was impossible. Left side— 
the specimen consists of the tube, ovary and a clear transparent 
cyst in the broad ligament. The tube measures 7 cm. in length, 
0.5 at thinnest, and 1 cm. at thickest part; the fimbriated end is 
occluded and the tube covered with numerous adhesions. 
The tube appears to lie in a depression between the intact por- 
tion of the ovary and the clear intra-ligamentous cyst beneath it; 
the peritoneal covering of the tube spreads out over the cyst, 
which is therefore intra-ligamentous. A portion of the ovary, 
measuring 4, 3 and 2 cm. in its various diameters, is present 
above the cyst, and presents numerous follicles and adhesions, 
while its lower margin appears to be continuous with the cyst 
wall. The cyst is 5 cm. in diameter, with thin, almost trans- 
parent walls, and is situated between the folds of the broad liga- 
ment. Extending across the anterior and inferior surface of the 
cyst is the thinned-out parovarium, which is about 8 cm. in length. 
The cyst contains a clear yellow fluid, containing many whitish 
particles in suspension, which under the microscope are seen to 
be very fatty compound granular bodies. The cyst is unilocular, of a glistening white color interiorly, 
with numerous ecchymotic patches. Scrapings show it to be lined 
by cuboidal and roundish epithelial cells, with large vesicular 
nuclei; many of the cells are fatty. 
Microscopic sections of the tube show most exquisite miliary 
tuberculosis of the mucous membrane, in which the tubercle 
bacilli were demonstrated in small numbers. Sections through 
the wall of the cyst show it to be a typical hydrops folliculi; for 
it is lined by cuboidal epithelical cells, with large nuclei, which 
are arranged in several layers over the greater part of the interior 
of the cyst; though here and there they are arranged in only a 
single layer. 
This case, as far as I can learn, is unique, and proves absolutely 
that growths developed from the Graafian follicles may invade 
the broad ligament; and teaches us that all tumors within the 
folds of the broad ligament are not of Wolffian body origin. 
Having thus proved that a Graafian follicle growth may be- 
come intra-ligamentous, it only remains necessary to prove that 
under certain circumstances its epithelium may become ciliated in 
order to fulfil all the requirements necessary for the development 
of the ciliated papillary intra-ligamentous cystomata from the 
Graafian follicle. 
Fortunately, I am also able to confirm from my own experi- 
ence the observation of Von Velits, that the epithelial lining of 
the Graafian follicle may be ciliated. 
The investigations of Leod,37 Leydig,59 and Nussbaum38 on 
the ovaries of the lower animals, showed that the granulosa cells 
of the frog and others of the lower animals were always ciliated 
during the period of “heat;” and the theoretical deductions of 
Marchand and Flaischlen prepared the way for the discovery of 
cilia in the Graafian follicles in man. 
Over a year ago, in a case of small cystic ovaries, I found 
several of the dilated follicles lined by ciliated epithelium. This 
was soon followed by several others, some three or four cases in 
all. In one instance, the ovary contained at least five or six fol- 
licles in which cilia in motion were demonstrated. Unfortunately, 
these observations were made at a period in which I did not keep 
accurate records of my work, so that I am unable to give all the 
minutiae concerning the specimens. 
About the same period, but little independently of one another, 
Von Velits made similar observations, and was fortunate enough in several eases to obtain sections of Graafian follicles in which 
ova were still visible. The follicles were lined by a single layer 
of cylindrical ciliated epithelium, of which he gave excellent 
drawings. 
These observations prove beyond all doubt that not only the 
simple papillary cysts may develop from the Graafian follicles, 
but also the ciliated papillomata and even the ciliated intra-liga- 
mentous papillomata. For, in the third and fourth cases, we 
proved that the non-ciliated papillomata might, in some cases, 
develop from the Graafian follicle; and in the last two observa- 
tions, that under certain circumstances the Graafian follicle might 
become ciliated and even grow within the folds of the broad liga- 
ment. Now, we have only to suppose the papillary formation, 
going on in Cases III and IY, to occur in a Graafian follicle with a 
ciliated membrana granulosa, in order to have a ciliated papil- 
lary cystoma developed; and if the follicle should happen to grow 
within the folds of the broad ligament, as in Case Y, we would 
have a ciliated intra-ligamentous papillary cyst produced. 
In view of these observations, I feel no hesitancy in concluding 
with Marchand that there is no generic difference between the 
ciliated and non-ciliated papillary cystomata, for their origin is 
the same, namely, from the Graafian follicle. 
I desire to call attention to the fallacy of supposing that the 
sand body, “ psammon-koerperchen,” is pathognomonic of the 
papillary cystomata, as has been stated by Flaischlen,23 Yon 
Yelits32 and others ; for in several cases which I have examined 
they were entirely absent from the growth. And the fact, long 
since demonstrated by Yirchow,40 that similar growths occur in 
the brain and other organs, completely robs their presence of any 
significance whatever. 
It was upon their presence near the ciliated Graafian follicles, 
that Von Velits32 based his statement that these follicles repre- 
sented the earliest stage in the development of the papillary cys- 
tomata, even though they exhibited no trace of papillary growths. 
In view of these facts it can not be considered that Yon Velits 
demonstrated the development of the papillary cystomata from the 
Graafian follicle, as he claimed; and therefore it is believed that the 
first proof of this mode of development is presented in this article. 
In conclusion, I will sum up the results of my work, and in so 
doing will not commit myself to any single theory of development 
to the exclusion of all others; for I believe that they may be de- veloped from one of several sources; and it is not impossible that 
different portions of the same growth may have developed from 
different structures, though I am unable to state positively that 
this is ever the case. 
As the result of my observations, I would almost entirely reject 
the Wolffian body theory and consider the growths to be purely 
ovarian. The papillary ovarian cystomata may be derived from 
the following sources: 
1. The Graafian follicle. This is probably the usual point of 
origin for the development of these growths; and according as the 
membrana granulosa is ciliated or not, so the growth will be of the 
ciliated or non-ciliated variety ; and according as the affected 
follicles grow within the folds of the broad ligament or not, so 
the growth will be intra-ligamentous or not. 
2. The germinal epithelium. This is the most frequent and 
perhaps the only source of origin for the superficial papilloma, 
and probably is frequently the starting point for the usual form 
of the multiloeular papillary cystomata. 
3. The tubal epithelium. From a consideration of the condi- 
tions in Case I, it is probable that some cases are developed from 
ingrowths of the epithelium of the tube into the stroma of the 
ovary. This mode of origin is, however, not yet absolutely proven. 
These conclusions tend to prove that the work of all the later 
investigators in this direction, except those who accepted the 
Wolffian body theory of development, has been accurate and of 
real scientific value; but no one observer seems to have met with 
all of the different forms of development presented in this article. 
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