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 SIXTH EDITION

BROWSE’S
INTRODUCTION TO
THE SYMPTOMS & SIGNS
OF SURGICAL DISEASE
 SIXTH EDITION

BROWSE’S
INTRODUCTION TO
THE SYMPTOMS & SIGNS
OF SURGICAL DISEASE
Edited by
James A. Gossage BSc MS FRCS
Consultant General Upper GI Surgeon
Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Matthew F. Bultitude MBBS MRCS MSc FRCS(Urol)

Consultant Urological Surgeon and Clinical Director for Transplant, Renal and Urology,
Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Steven A. Corbett BSc PhD FRCS FRCS(Tr&Orth)

Consultant Orthopaedic Surgeon
Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Fortius Clinic, London, UK

Associate Editors
Katherine M. Burnand FRCS(Paed Surg)
Consultant Paediatric Surgeon, St George’s Hospital, London, UK

Rajiv Lahiri BSc MD(res) FRCS

Senior Fellow in HPB Surgery, Royal Surrey County Hospital, Guildford, UK

Emeritus Editor
Kevin Burnand MBBS FRCS MS
Emeritus Professor of Surgery, Kings College, London, UK
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2021 by Taylor & Francis Group, LLC

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 Contents

Obituary vii
Foreword ix
Contributors xi
1 History-taking and clinical examination 1
James A Gossage and Rajiv Lahiri
2 The heart, lungs and pleura 37
Richard Leach
3 The brain, central nervous system and peripheral nerves 79
Peter Bullock
4 The skin and subcutaneous tissues 111
Kavan S Johal, Samer Saour and Pari-Naz Mohanna
5 Major injuries 169
Rajiv Lahiri
6 Bones, joints, muscles and tendons 185
Steven A Corbett, Adil Ajuied, Richard Keen and Jonathan Rees
7 Upper limb 225
Steven A Corbett, W James White and Donald Sammut
8 Lower limb 265
Steven A Corbett, Ian P Holloway, David Houlihan-Burne and Andrew Roche
9 Spine and pelvis 305
Jason R Harvey, Glyn Towlerton and Steven A Corbett
10 The arteries, veins and lymphatics 329
Bijan Modarai and Ashish Patel
11 The mouth, tongue and lips 373
Mark McGurk and Navin Vig
12 The neck 399
Johnathan G Hubbard
13 The breast 451
Jenna Morgan and Lynda Wyld
14 The abdominal wall, hernias and the umbilicus 469
James A Gossage and Katherine M Burnand
15 The abdomen 491
James A Gossage and Katherine M Burnand

v
 Contents

16 The rectum and anal canal 549

Mark George
17 The kidneys, urinary tract and prostate 573
Ben Challacombe and Matthew F Bultitude
18 The external genitalia 589
Arun Sahai and Matthew F Bultitude
Index 617

Companion website – visit www.routledge.com/cw/gossage for digital resources to

supplement this textbook including self-assessment material, video animations and an
image library.
vi
 Obituary

Professor Sir Norman Browse He returned to the post of lecturer at the academic
department of surgery at the Westminster Hospital
Norman was born in 1931 within the sound of
under the chairmanship of Professor Harold Ellis
“Bow Bells” which he said entitled him to be called
(where Sir Roy Calne was the senior lecturer and Sir
a “Cockney”! He was educated in East London and
Barry Jackson was the SHO!)
won a scholarship to East Ham Grammar School.
He was appointed to the senior lectureship in
From here, he was accepted for medical training
the academic department of surgery at St Thomas’
at St Bartholomew’s Hospital Medical School in the
Hospital in 1966 under the chairmanship of
city of London. He did his national service in the
Professor John Kinmonth while still in his early
RAMC on Cyprus after qualification before he began
30’s. Over the next 30 years, he developed his skills
his surgical training with Professor Robert Milnes-
in vascular surgery, research and teaching. He was
Walker in Bristol.
promoted reader and then given a personal chair
He then went to the USA as a Harkness fellow
in vascular surgery before taking over the chair-
at the Mayo clinic where he was supervised by John
manship of the academic department of surgery at
Sheppard. He wrote his thesis and a book on “the
St Thomas’ when Professor Kinmonth retired in
Physiology and Pathology of bed rest” based on his
1981.
research carried out at the Mayo.

Sir Norman and Lady Browse

vii
 Obituary

During this time, he wrote many seminal papers the development of the “Exit Examination” and the
on venous thrombosis, venous ulceration, atheroma Research Fellowship scheme which has provided £40
and aneurysm formation, congenital vascular mal- million pounds to date for young surgeons to carry
formations and lymphoedema. He also wrote books out a period of research in their training.
on venous and lymphatic disease and contributed He wrote the first edition of this book in 1978
chapters to many other surgical books. He gave and it became an immediate best seller because of
many prestigious lectures and was a visiting profes- its clear and well-structured approach, combined
sor at famous universities all over the world. with excellent illustrations and clinical pictures. The
He was on the court of examiners of the Royal first edition was dedicated to his wife Jeanne who
College of Surgeons of England, the Specialist he met at medical school who was from the island
Advisory Committee in Surgery and was then of Alderney. The Browses retired to this island and
elected to the council of the RCS England before Norman was elected as its President for nine years.
becoming its President in 1992. During his time in Jeanne died just over a year before Norman who
office, he made many far reaching changes including died on September 12th, 2019 at the age of 87.

viii
 Foreword

Since the last edition of this book, both Sir Norman and he felt could be extremely dangerous if rigidly
and Lady Browse have died on their beloved Island applied.
of Alderney. Norman was my boss, my mentor and He believed in constructing a differential diag-
then my colleague and friend. I was honoured when nosis that could be whittled down until the correct
he asked me to help him with the preparation of the diagnosis became apparent, rather than a problem-
fourth edition and I suggested that we ask my friends orientated approach or the development of a working
John Black and Bill Thomas to join us in bringing the diagnosis which, he also held, reduced the need for
book up to date. Norman and the three of us had an lateral thought.
interest in all the sub- specialities that make up “gen- It is ironic that when he himself developed marked
eral surgery” and we were all recognised as enthusi- dyspnoea on Alderney several years before his death
astic undergraduate and post- graduate teachers. he was referred to specialist cardiac services on the
Norman had an agile and organised mind, and ‘mainland’ where he underwent two unnecessary
he recognised the importance of a clear structure coronary interventions without improvement before
and the use of repetition in teaching trainees of all the correct diagnosis of ‘pulmonary fibrosis’ was
levels about conditions requiring surgical treat- eventually reached! So much for modern clinical
ment. He was always professional and courteous to acumen!
the patients in his care and meticulous in his ques- This book has stood the test of time because it
tioning and clinical examination. His clinical notes has been written in straightforward English, clearly
were legible, accurate and comprehensive. He was structured and filled with excellent clinical pictures
recognised throughout the United Kingdom as an and diagrams. This ethos has been maintained. It is
excellent ‘second opinion’ for patients with complex more comprehensive than the first edition with some
problems and was referred patients from all over the of the more idiosyncratic and rare conditions hav-
world with specialist vascular disorders for assess- ing been downsized or removed. The fifth edition
ment and treatment where possible. He was a neat was longer (which Norman did not like), as a con-
and precise surgeon who achieved and published sequence of the more comprehensive coverage of the
excellent results in challenging operations. sub-specialities, but this edition has been rigorously
His practice was based on an accurate clinical pruned and unhelpful illustrations removed.
diagnosis and he always championed the importance All the present editors and subeditors are well
of a careful history and a meticulous clinical exami- known to me and were selected because they have
nation before any special investigations were ordered excellent track records in teaching and writing about
or obtained. Not for him, the blanket diagnostic test surgery. As a consequence, the book retains its close
of a ‘CT or ultrasound scan’ of the abdomen in a association with Guy’s and St Thomas’ hospitals
patient presenting with abdominal pain before a dif- although many of the chapters have been revised by
ferential diagnosis had been developed! clinicians from other institutions.
He strongly disapproved of ‘surgical pathways’ Most of the original ‘Browse Book’ remains as new
and ‘clinical protocols’ which he felt removed the surgical diseases are rare, but fresh eyes and minds
need for brain usage and encouraged a false sense have ensured that outdated material has been removed
of security. He disliked the widespread use of proto- and unhelpful illustrations culled. Self-assessment
cols which he thought risked missing aberrant and feedback has been added and hopefully future editions
rare conditions in patients who fell outside the norm will make use of more multimedia platforms.
ix
 Foreword

I like to think that Norman would be pleased with producing such a tangible memorial to an outstand-
the new 6th edition and I would like to thank all the ing surgical clinician.
editors and contributors for all their hard work in
Kevin Burnand

x
 Contributors

Adil Ajuied BSc(Hons) MSc FRCS(Tr&Orth) James A Gossage BSc MS FRCS

Consultant Orthopaedic Surgeon Consultant General Upper GI Surgeon
Guy’s and St Thomas’ NHS Foundation Trust Guy’s and St Thomas’ NHS Foundation Trust
Honorary Senior Clinical Lecturer Honorary Senior Lecturer
King’s College London King’s College
London, UK London, UK
Peter Bullock FRCS MRCP Honorary Senior Lecturer
Consultant Neurosurgeon Karolinska Institute
King’s College Hospital Sweden
Honorary Neurosurgeon Jason R Harvey MBBS FRCSEd FRCS(Tr&Orth)
Guy’s and St Thomas’ NHS Foundation Trust Consultant Spinal Surgeon
and The Maudsley Hospital Wessex Spinal Unit
London, UK Southampton University Hospital
Matthew F Bultitude MBBS MRCS MSc Southampton, UK
FRCS(Urol) Fortius Clinic
Consultant Urological Surgeon and Clinical London, UK
Director for Transplant, Renal and Urology Ian P Holloway MBBS FRCS(Tr&Orth)
Guy’s and St Thomas’ NHS Foundation Trust Consultant Orthopaedic Surgeon and Clinical
London, UK Director for Orthopaedics
Katherine M Burnand FRCS(Paed Surg) London North West University Healthcare NHS Trust
Consultant Paediatric Surgeon London, UK
St George’s Hospital David Houlihan-Burne MBBS(Hons) BSc(Hons)
London, UK MRCS FRCS(Tr&Orth)
Ben Challacombe MS FRCS (Urol) Consultant Knee Surgeon
Consultant Urological Surgeon and Honorary Fortius Clinic
Senior Lecturer London, UK
Guy’s and St Thomas’ NHS Foundation Trust Three Rivers Knee & Sports Injury Clinic
and King’s College Middlesex, UK
London, UK Johnathan G Hubbard MD FRCS(Gen)
Steven A Corbett BSc PhD FRCS FEBS(Endocrine)
FRCS(Tr&Orth) Consultant Endocrine Surgeon
Consultant Orthopaedic Surgeon Guy’s and St Thomas’ NHS Foundation Trust
Guy’s and St Thomas’ NHS Foundation Trust Kings College Hospital
and Fortius Clinic London, UK
London, UK Kavan S Johal BMedSci(Hons) BMBS(Hons)
Mark George BSc MS FRCS MPhil FRCS(Plast)
Consultant Colorectal Surgeon Specialist Registrar in Plastic Surgery
Guy’s and St Thomas’ NHS Foundation Trust Guy’s and St Thomas’ NHS Foundation Trust
London, UK London, UK
xi
 Contributors

Richard Keen BSc PhD FRCP Ashish Patel FRCS

Consultant in Metabolic Bone Disease Clinical Senior Lecturer
Royal National Orthopaedic Hospital Vascular Surgery
Stanmore, UK King’s College Hospital
Rajiv Lahiri BSc MD(res) FRCS Guy’s and St Thomas’ NHS Foundation Trust
Senior Fellow in HPB Surgery London, UK
Royal Surrey County Hospital Jonathan Rees FRCP FFSEM MD
Guildford, UK Consultant Rheumatologist and Sports Physician
Richard Leach MD FRCP Fortius Clinic
Consultant Physician and Honorary Reader in Honorary Senior Lecturer
Medicine Queen Mary College
Clinical Director Pulmonary and Critical Care London, UK
Medicine Andrew Roche MBChB MSc FRCS(Tr&Orth)
Guy’s and St Thomas’ NHS Foundation Trust Consultant Foot and Ankle Surgeon
London, UK Chelsea & Westminster Hospital
Mark McGurk MD FRCS DLO FDSRCS Fortius Clinic
Professor of Oral & Maxillofacial Surgery London, UK
Director of Head & Neck Centre Arun Sahai PhD FRCS(Urol)
UCL Division of Surgical Interventional Sciences Consultant Urologist and Honorary Senior
King Edward VII’s Hospital Lecturer
London Bridge Hospital Department of Urology
UCL Hospital Guy’s and St Thomas’ NHS Foundation Trust
London, UK London, UK
Bijan Modarai FRCS
Donald Sammut FRCS FRCS(Plast)
Professor and King’s Chair
Consultant Hand Surgeon
Vascular and Endovascular Surgery
OneWelbeck Clinic
Guy’s and St Thomas’ NHS Foundation Trust
Marylebone, London
London, UK
Circle Bath Hospital
Pari-Naz Mohanna MBBS BSc MD FRCS(Plast) Bath, UK
Consultant Plastic and Reconstructive Surgeon
Guy’s and St Thomas’ NHS Foundation Trust Samer Saour MB BCH BAO MSc
London, UK FRCS(Plast)
Consultant Plastic Surgeon
Jenna Morgan MBChB MRCS(Ed) DipMedEd PhD
St George’s Hospital
NIHR Clinical Lecturer in Surgery
London, UK
Department of Oncology and Metabolism
University of Sheffield Glyn Towlerton MBBS(Hons) BSc MRCP
Sheffield, UK FRCA FFPMRCA FIPP
Higher Surgical Trainee Consultant in Pain Medicine
Doncaster and Bassetlaw Teaching Hospitals NHS Chelsea & Westminster Hospital NHS
Foundation Trust Foundation Trust
Doncaster, UK London, UK

xii
 Contributors

Navin Vig MBBS BDS FRCS(OMFS) PhD Lynda Wyld BMedSci MBChB(Hons)
Specialty Registrar, Oral & Maxillofacial Surgery PhD FRCS(GenSurg) FEBS
and Clinical Research Fellow Professor of Surgical Oncology
UCL Hospital Department of Oncology and Metabolism
London, UK University of Sheffield
W James White MBBS BSc(Hons) Sheffield, UK
FRCS(Tr&Orth) Honorary Consultant Oncoplastic Breast Surgeon
Consultant Trauma and Orthopaedic Surgeon Doncaster and Bassetlaw Teaching Hospitals NHS
Guy’s and St Thomas’ NHS Foundation Trust Foundation Trust
London, UK Doncaster, UK

xiii
 History-taking and clinical
examination
1 JAMES A GOSSAGE AND RAJIV LAHIRI

How to take the history 2 History and examination of a lump 29

A detailed history of pain 9 History and examination of an ulcer 33
Clinical examination 12

You must be alert from the moment you first see then be asked in private. It is also often helpful if a
the patient. Use your eyes, ears, nose and hands in chaperone is present.
a systematic fashion to collect information from Talk with patients or, better still, let them talk to
which you can deduce the diagnosis. The ability to you. At first, guide the conversation, but do not dic-
appreciate an unusual comment or minor abnor- tate it. Treat patients as rational, intelligent human
mality can lead you to the correct diagnosis. This beings. They know what worries them better than
skill only develops from the diligent and frequent you do, but they are visiting a doctor to obtain a diag-
practice of the routines outlined in this chapter. nosis and if necessary receive treatment. At all stages,
Always give the patient your whole attention and never explain what you are doing, and why you are doing it.
take short cuts. All questions should be put in simple plain lan-
In the outpatient clinic, have patients walk into guage, avoiding medical terms and jargon, and using
the consulting room to meet you, rather than find- lay expressions as much as possible. When a patient
ing them lying undressed on a couch in a cubicle. is not fluent in English, an interpreter is required.
General malaise and debility, breathlessness, cya- When conducting an interview through an inter-
nosis and difficulty with particular movements or an preter, keep your questions short and simple, and
abnormal gait are much more obvious during exer- have them translated and answered one at a time.
cise. Patients like to know to whom they are talking. You should not use leading questions. Allow patients
They are probably expecting to see a specific doctor. to choose their own answers. Do not say, ‘Did the
You should tell patients your name, and explain why you pain move to the right-hand side?’ This is a lead-
are seeing them. ing question because it implies that it should have
A parent, spouse or friend who is accompanying moved in that direction, and an obliging patient will
the patient can often provide valuable information sometimes answer yes just to please you. The patient
about changes in health and behaviour not noticed should be asked whether the pain ever moves.
by the patient. Remember, that many patients are When the answer is yes, the supplementary ques-
inhibited from discussing their problems in front of tion is ‘Where does it go to?’ If, however, patients
a third person. It can also be difficult if the rela- fail to understand the question, a number of possible
tive or friend, with the best of intentions, constantly answers may have to be proposed, which can then be
replies on behalf of the patient. When the time confirmed or rejected.
comes for the examination, the friend or relative Remember that a question that you do not think
can be asked to leave and further questions can is leading the patient may be interpreted incorrectly
1
 History-taking and clinical examination

if they do not realize that there is more than one another doctor. It is also worth asking ‘What is the
answer. For example, ‘Has the pain changed?’ can be problem that you want me (e.g. the surgeon) to sort
a bad question, as there are a variety of ways in which out?’ If you ask ‘What is the matter?’, the patient will
the pain can change. It can alter in severity, nature, often tell you what they think is their diagnosis, or
site, etc., but the patient may be so disturbed by the what they have been told by others. It is better not
intensity of the pain that they think only of its sever- to know what the patient thinks is the diagnosis, or the
ity and forget the other features that have altered. diagnoses given by other doctors (see the point about
In such situations, it often helps to include possible referral letters above), because neither may be cor-
answers to the question, for example, ‘Has the pain rect. Try to tease out the patient’s complaints and
moved to the top, bottom, or side of your abdomen problems and come to your own conclusions!
or anywhere else?’, ‘Has the pain got worse, better or Complaints should be listed in order of severity,
stayed the same?’ or ‘Can you walk as far, less far or with a record of precisely when and how they started.
the same distance that you could a year ago?’ Whenever possible, it should be noted why the patient
The patient should provide the correct answer is more concerned with one complaint than another.
providing you ask the question correctly. Do not be
overconcerned about the questions – worry about HISTORY OF THE PRESENT
the answers, and accept that it will sometimes take a COMPLAINT
long time and a great deal of patience and persever-
ance to get a good history. The full history of the main complaint or com-
At some stage, you will read the referral letter, which plaints must be recorded in detail, with precise dates.
may suggest a diagnosis. It is often better to read this It is important to get right back to the beginning of
after you have taken your own history as it can bias the problem. For example, a patient may complain of
your independent opinion. a recent sudden attack of indigestion. When further
questioning reveals that similar symptoms occurred
some years previously, their description should be
How to take the history included in this section.

The history should be taken in the order described

below and in Revision panel 1.1. Try not to write and talk
REMAINING QUESTIONS ABOUT
to the patient at the same time. It is, however, important THE AFFECTED SYSTEM
to document dates and times and drug history and When a patient complains of indigestion, for
dosage accurately, which you may not recall after you example, it is sensible, after recording the history
have finished the examination and left the room. Brief of the indigestion, to move on at this point to other
notes as you talk to the patient are therefore essential. questions about the alimentary system.
Always make sure you know, and record, the patient’s
name, age, sex and occupation. Whenever you write a
note about a patient, whether it is a short progress
SYSTEMATIC DIRECT QUESTIONS
report or a full history, make sure that you write These are direct questions that every patient
down the date and time that the patient was seen. should be asked, because the answers may amplify
your knowledge about the main complaint and will
THE PRESENT COMPLAINT/ often reveal the presence of other disorders of which
PROBLEM the patient was unaware, or thought irrelevant. An
absence of associated symptoms is often just as
Start by asking the patient what is their main important as positive answers. The standard set of
complaint and record the answer. Ask the patient to direct and important supplementary questions is
use their own words to describe exactly what it is that described in detail below because they are so impor-
they have found to be wrong with themselves, and tant. It is essential to know them by heart because it is
not what they have been told is wrong, perhaps by very easy to forget to ask some of them.
2
 How to take the history

Revision panel 1.1

SYNOPSIS OF A HISTORY Vaginal discharge. Dysmenorrhoea. Dyspareunia.

Previous pregnancies and their complications.
Names. Age and date of birth. Sex.
Prolapse. Urinary incontinence. Breast pain. Nipple
Marital status. Occupation. Ethnic group.
discharge. Lumps. Skin changes
Hospital or practice record number
e. Nervous system
Present complaints or problems
Preferably in the patient’s own words Changes of behaviour or psyche. Depression.
Memory loss. Delusions. Anxiety. Tremor. Syncopal
History of the present complaint attacks. Loss of consciousness. Fits. Muscle
weakness. Paralysis. Sensory disturbances.
Include the answers to the direct questions concerning
Paraesthesias. Dizziness. Changes of smell, vision
the system of the presenting complaint
or hearing. Tinnitus. Headaches
Systematic direct questions f. Musculoskeletal system
a. Alimentary system and abdomen
Aches or pains in muscles, bones or joints. Swelling
Appetite. Diet. Weight. Nausea. Dysphagia. joints. Limitation of joint movements. Locking.
Regurgitation. Flatulence. Heartburn. Vomiting. Weakness. Disturbances of gait
Haematemesis. Indigestion pain. Abdominal pain.
Jaundice. Abdominal distension. Bowel habit. Past medical history
Nature of stool. Rectal bleeding. Mucus. Slime. Previous illnesses. Operations or accidents. Diabetes.
Prolapse. Incontinence. Tenesmus Rheumatic fever. Diphtheria. Bleeding tendencies.
Asthma. Hay fever. Allergies. Tuberculosis. Sexually
b. Respiratory system
transmitted diseases. Tropical diseases
Cough. Sputum. Haemoptysis. Dyspnoea. Hoarse-
ness. Wheezing. Chest pain. Exercise tolerance Drug history
Include all prescription and over the counter medica-
c. Cardiovascular system
tions. Always check for allergies
Dyspnoea. Paroxysmal nocturnal dyspnoea.
Orthopnoea. Chest pain. Palpitations. Ankle swell- Immunizations
ing. Dizziness. Limb pain. Walking distance. Colour BCG. Diphtheria. Tetanus. Typhoid. Whooping cough.
changes in hands and feet Measles

d. Urogenital system
Family history
Loin pain. Frequency of micturition including noc- Causes of death of close relatives. Familial illnesses in
turnal frequency. Poor stream. Dribbling. Hesitancy. siblings and offspring
Dysuria. Urgency. Precipitancy. Painful micturition.
Polyuria. Thirst. Haematuria. Incontinence Social history
Marital status. Sexual habits. Living accommodation.
In males: Problems with sexual intercourse and
Occupation. Exposure to industrial hazards. Travel
impotence
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