[Reprinted from 
The Philadelphia Polyclinic, 
Vol. VJ, January 1, 1898, No. 1.] 
REMOVAL OF CERTAIN BENIGN BREAST TUMORS BY THOMAS' TRAP-DOOR 
INCISION AND HIDDEN CICATRIX METHOD. 
BY THOMAS S. K. MORTON, M.D. 
Professor of Surgery in the Philadelphia Polyclinic. 
In the New York Medical Journal of 
April, 1882, page 337, Dr. T. Gaillard 
Thomas, under title "On the Removal of 
Benign Tumors of the Mamma without 
Mutilation of the Organ," described a new 
operation by means of which tumors of a 
benign nature, especially the adenomata 
of young girls, and, again, especially those 
growths situated in the lower quadrants of 
the organ could be safely and easily re- 
moved without mutilation of the glandular 
structure or the infliction of an ODservable 
cicatrix. He holds that the operation is en- 
tirely inappropriate for malignant tumors or 
for very large or very small benign growths. 
He reported twelve cases in which he had 
most successfully and satisfactorily applied 
the procedure. These included : fibromata, 
lipomata, cysts, and adenomata, which va- 
ried in size from a hen's egg to that of a 
duck, or a little larger. 
His description of the operation is as fol- 
lows, " The patient standing erect and the 
mamma being completely exposed, a semi- 
circular line is drawn with pen and ink ex- 
actly in the fold which is created by the fall 
of the organ upon the thorax. The line en- 
circles the lower half of the breast at its 
junction with the trunk. As soon as it has 
dried, the patient is anesthetized, and with 
the bistoury the skin and areolar tissues are 
cut through, the knife exactly following the 
ink line just mentioned, until the thoracic 
muscles are reached. From these the 
mamma is now dissected away until the line 
of dissection represents the chord of an arc 
extending from extremity to extremity of 
the semi-circular incision. The lower half 
of the mamma which is now dissected off is, 
after ligation of all bleeding vessels, turned 
upward by an assistant and laid upon the 
chest walls just below the clavicle. An in- 
cision is then made upon the tumor from 
underneath, by the bistoury, a pair of short 
vulsellum forceps firmly fixed into it, and, 
while traction is made by these, its connec- 
tions are snipped by scissors, the body of 
the tumor being closely adhered to in this 
process, and the growth is removed. All 
hemorrhage is then checked and the breast 
put back into its original position." 
The outer or cutaneous surface of the 
breast is uninjured, and the only alteration 
of the organ is the possible depression over 
the site of removed tumor. Dr. Thomas 
recommended glass-tube drainage, and the 
close approximation of the skin edges by 
fine silk stitches introduced close to the 
wound margins by means of round sewing 
needles so as to avoid as much as possible all 
cicatrices. He was agreeably disappointed 
in most of his cases to find that not the 
slightest depression or deformity was subse- 
quently to be found. "The only sign of 2 
the operation which remains to mark its 
performance, if it is done in a neat, careful 
and surgical manner, is a delicate cicatricial 
semi-circular line, which is in great degree 
concealed by the folding of the skin as 
the breast hangs downward, and a spot of 
cicatricial tissue where the drainage tube 
prevented union by first intention." 
Although this operation as proposed by 
Dr. Thomas has very manifest advantages 
in a limited number of carefully selected 
cases, it has apparently been forgotten by 
surgeons generally, and has been completely 
ignored by most of the text-books. Nor has 
it fared much better in periodic literature, 
for the writer has only been able to find the 
few following references to the procedure. 
Bryant, "Diseases of the Breast," page 
107, alludes to Thomas' operation, but 
makes no comment. 
Alexander Jamieson, of Shanghai, China, 
British Medical Journal, June 9, 1888, 
page 1216, reports four cases of his own 
and one of his colleague, Dr. Boone, in all 
of which primary union and exceedingly 
satisfactory results were obtained. He was 
most gratified with the operation and its 
beautiful results. An illustration from a 
photograph accompanies the article. In 
view of the risk of adenomata of the female 
breast developing into recurrent fibro-cysto- 
mata he has always urged eaily extirpation of 
such tumors. But a seriously deformed breast, 
in the estimation of most young women, is a 
disproportionate price to pay for the avoidance 
of a danger which at worst is only probable. 
Hence he welcomed the advent of the new 
operation, as patients could be persuaded the 
more readily to permit operation at an early 
stage if assured that no serious deformity 
would result. In the same journal, Decem- 
ber 2, 1893, page 1209, he reports an 
additional case and again warmly comends 
the operation to his fellow surgeons. 
John D. Flay ward, British Medical Jour- 
nal, February 23, 1889, page 410, reports the 
removal of an adenoma the size of an orange 
by this method. No vessels required liga- 
tion, the drain tube was removed on the 
second day, and the case was discharged 
cured in a week. It was impossible to see 
any difference between the injured breast 
and its fellow except upon raising the organ 
completely. 
The writer presents the following case as 
illustration that Thomas' operation can be 
readily and successfully applied to encapsul- 
ated or benign growths in the upper as well 
as the lower quadrants of the breast: 
Mrs. X. W., aged 36 years, white, house- 
wife, entered the Polyclinic Hospital April 
4, 1895. Her mother died at the age of 
53 from an "abdominal tumor." Other- 
wise the family history was negative. 
Eleven years ago she bore a healthy child 
which she nursed. Perineum and cervix 
were then lacerated, but subsequently re- 
paired. She has always enjoyed the best of 
health. Five months before admission she 
first noticed a lump in the upper and outer 
portion of the right breast. It was then as 
large as a marble. During the interval it 
had steadily increased, and during the pre- 
ceding four weeks had given rise to shooting 
pains. Her weight had not diminished nor 
had her general strength or spirits suffered. 
Upon examination, the breast was found 
to be the site of a hard, extremely movable 
tumor in its uppor and outer quadrant. It 
was not especially sensitive to pressure. In 
size it was as large as a duck's egg. It could 
be pressed downward from above so as to 
become subcutaneous at the nipple. A 
finger tip passed down through the thin skin 
about the nipple could accurately define the 
inferior surfaces of the growth. It was 
dense, elastic and perfectly smooth. The 
extent of its movability was exceptional: it 
appeared to have hollowed out a large cavity 
in the cellular tissue by its constant excursions. 
The finger determined that there were no 
adhesions upon the under surface of the tumor. 
The axillary glands were not enlarged or 
painful to pressure. Diagnosis of adenoma 
was made and the Thomas method of re- 
moval decided upon. 
It was found easily feasible in this case to 
turn up the breast as a flap or trap door so 
as to extract the growth without leaving a 
disfiguring cicatrix. An incision five inches 
in length was made, semi-circular in form, 
in the line of the fold formed at the junction 3 
of the lower portion of the breast skin with 
that of the chest wall. 
This'was carried down through a consid- 
erable amount of fat until the sheath of the pec- 
toral is major was exposed. The loose cellular 
attachments of this to the capsule of the breast 
was then with great ease broken up by blunt 
dissection and an occasional snip of the scis- 
sors until the breast could be turned upwards 
upon the chest wall below the clavicle. The 
posterior wall of the capsule was now opened 
in a direction radial to the nipple over the 
tumor. This was found to be encapsulated 
and very loosly adherent to the pocket among 
the gland acini, which it had evidently 
formed by its movements. Blunt dissection 
by a forefinger freed it at a sweep at all 
points save the upper and outer, where a 
firm adhesion was discovered, which re- 
quired division by the knife, but without 
opening the capsule of the growth. No 
ligatures were required. The gland was 
turned down into its normal position and the 
skin margins of the wound united by a sub- 
cuticular continuous suture of silk. No 
drainage was used. A snug and copious 
dressing was so applied as to obliterate the 
cavity from which the tumor had been 
enucleated. Acetanilid was dusted along 
the suture line. On the fifth day the suture 
was removed and primary union found. No 
deformity of the breast was observable. 
One week later it was difficult to see any 
difference between the breasts. The cicatrix 
could only be seen by raising the breast, ex- 
cept at each side where for about an inch a 
hair line cicatrix-the extremities of the in- 
cision-could be observed, and this only upon 
close inspection. 
Dr. Joseph McFarland reported the tumor 
to be adeno-sarcoma. 
The woman was kept under observation for 
a period of more than two years and during 
that time her general health continued ex- 
ceptionally good. No difference could be 
detected between the two breasts except upon 
close inspection, when the extremities of the 
incision could be observed. The hollow 
made in the gland by the former presence of 
the tumor had been obliterated. The Philadelphia Polyclinic 
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