Is It an Either/Or or a 50-50 Proposition?

The usual suspects stand 7½ inches high in a stack next to my computer. They moderate my dogma against what I think lazy or muddled use of punctuation or language by nicely telling me that I am wrong or, worse, that I have become woefully out of date.

No, I don’t wear a string of pearls, hang my reading glasses around my neck, stuff a tissue in the sleeve of my cardigan sweater, or wear my hair swept up in a bun, though my gray strands have thickened to streaks that I fear will dominate my hair soon enough. But I do become cranky about usage trends that render the language imprecise.

My problem is the slash or virgule. It seems to pop up everywhere, from a syllabus for a graduate class to a book assigned in another class. On the syllabus, the assessment subsection head includes “Exam/Term Paper and Class Participation.” Good, I thought, I will be able to pick whether to take the exam or write a paper. But no, as I read on I see there is no choice. The exam is to be written as an essay. Should that expression then be considered a compound modifier of a compound word and expressed with an en dash instead of a slash—“examination–term paper”? The book, on the other hand, discusses a collaborative “Harvard/MIT” study. Clearly, this should have been a hyphen rather than a slash.

But most frequently, I find excessive use of the virgule in the medical research articles I edit. Its prevalence in these articles always surprises me because by nature the virgule is ambiguous while science writing aims at precision—to the point of putting readers to sleep: no active verbs, few identifiable subjects, only statements that remain within the bounds of the data, and no causation, just associations.

So am I justified in being annoyed at what I consider an over-reliance on the slash? As a reader, I favor words and punctuation that make ideas clear. And while I am scrupulous about taking out an and/or construction, as is the mandate of our style manual, by stretching “red and/or white” to “red, white, or both,” I consider my irritation justified when confronted with extending its use to what was submitted in a table footnote for an article I recently edited:

            Rescue was defined as any pharmacological/electrical/surgical intervention for the termination/prevention of AF [atrial fibrillation]/flutter…

I dutifully changed it:

            Rescue was defined as any pharmacological, electrical, or surgical intervention for the termination or prevention of AF [atrial fibrillation] or flutter…

Although I was correct in determining that the slashes suggested an alternative, I could have guessed they meant a series.

Before checking the books, I confirm that the symbol of the virgule, which comes from the Latin virgula, “a little bough, twig; a rod, staff,”1 is defined as a slash in Merriam-Webster’s Collegiate Dictionary.2 Clearly, it looks like what it means, a visual mnemonic perhaps? My understanding of the punctuation mark is that the virgule can mean and or it can mean or, or as my poet-husband suggests, it classically means and/or.

So now to the stack. First up, the AMA Manual of Style,3 which in the introductory paragraph of the Forward Slash (Virgule, Solidus) section says that the virgule “is used to represent per, and, or or and to divide material (eg, numerators and denominator in fractions; month, day, and year in dates [only in tables and figures]; lines of poetry).” Then comes the first major discussion under the section, which says that the slash expresses equivalency “[w]hen 2 terms are of equal weight in an expression and and is implied” and provides the following example:

The diagnosis and initial treatment/diagnostic planning were recorded.

With this definition in mind, how do my above examples stand up to the test? MIT would probably not quibble with being viewed as equivalent to Harvard, but I still think in this case they are functioning, in their capacity as the generators of a study, as a compound modifier and should be hyphenated, even though and is implied. I think the same goes for my “exam/essay” example because and is not implied. They are a single concept as the major assessment for the class. And for my table footnote, while they represent equivalent interventions, the word and is not implied, but the expression “termination/prevention” could have been left alone as equivalent ideas. However, I think changing “AF/flutter” to “AF or flutter” was correct because I don’t think the experience is equivalent. (However, I am told by one of our medical editors that AF/flutter is so constructed because a patient’s heart rhythms may vacillate between the 2 states so that treatment and outcome are similar, thereby, demonstrating another example of the virgule serving as a visual reality.)

Fowler’s Modern English Usage4 and The Elements of Style5 are silent on the matter. The Associated Press Stylebook6 allows its use only to describe “phrases such as 24/7 or 9/11” and advises writers and editors to “otherwise confine its use to special situations, as with fractions or denoting the ends of a line in quoted poetry.”

The Chicago Manual of Style7 says, “A slash most commonly signifies alternatives. In certain contexts it is a convenient (if somewhat) informal shorthand for or. It is also used for alternative spellings or names. Where one or more of the terms separated by slashes is an open compound, a space before and after the slash can be helpful.” Although coming at it from the alternative angle rather than equivalent angle, I think my editing still stands. Nevertheless, I think the Chicago Manual captures the spirit of the slash in response to the speed brought on by the age of the Internet and people like my boss, who said, “I like it. It’s fast.”

As for me, the confusion of meaning slows me down. I vote for words.—Beverly Stewart, MSJ

1. University of Notre Dame. Latin dictionary and grammar aid Web page. Accessed July 16, 2012.

2. Virgule. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA; Merriam-Webster Inc; 2003:1397.

3. Iverson C, Christiansen S, Flanagin A, et al. AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007.

4. Burchfield RW. Fowler’s Modern English Usage. 3rd rev ed. New York, NY: Oxford University Press; 2004.

5. Strunk W, White EB. The Elements of Style. 4th ed. New York, NY: Longman; 2000.

6. Goldstein N, ed. The Associated Press Stylebook and Briefing on Media Law. New York, NY: Basic Books; 2007.

7. The Chicago Manual of Style. 16th ed. Chicago, IL: University of Chicago Press; 2010.

Questions From Users of the Manual

Q: We do not find anything in the manual on how to treat “24/7.” Would you recommend spelling it out?

A: You are right. We don’t address this. But Webster’s 11th does. Both “24-7” and “24/7” are offered as equal variants. I think the latter is more common and would prefer that, without spelling it out.

Q: I understand that human genes are set all caps and italic, with the protein products set all caps and roman. But what to do with proto-oncogenes? Do the examples in section 15.6.2 indicate that, if the c- prefix is used, the lowercase (retroviral) form of the 3-letter oncogene is always used, regardless of whether we’re dealing with humans or mice? I am often presented with c-KIT, c-Kit, and c-kit in one document and would appreciate a clear explanation.

A: For oncogenes, it would always be c-kit and then, based on page 633 of the style manual, KIT for the human gene homologue and Kit for the mouse gene homologue.

Q: To follow your reference style, if “et al” is used, is a period used after “al”? And should the reference number be set as a superscript?

A: To answer your second question first, yes, the reference number should be set as a superscript if you follow the style set forth in the AMA Manual. And unless “et al” ends the sentence, “al” would not be followed by a period (even though it is an abbreviation).—Cheryl Iverson, MA

Questions From Users of the Manual

Q: A colleague and I both remember seeing in a style manual that an en dash should be used between 2 words of equal weight. However, we checked the AMA Manual of Style and saw that this was not a supported use of the en dash. Did this guideline appear in a former edition of the AMA Manual, or did we just pick this idea up from another source?

A: No, I don’t believe we have ever recommended an en dash between 2 words of equal weight. It is the hyphen that we recommend between 2 words of equal weight. See the middle of page 346 of the 10th edition, with the examples of “blue-gray eyes” and “blue-black lesions.” We recommend use of the en dash when the items on either side are not of equal weight (eg, one element consists of 2 words or a hyphenated word or a compound). There are examples at the bottom of page 352 and the top of page 353.

Q: Is it appropriate to abbreviate echocardiography as ECHO or echo in documents that describe the use of echocardiography during the treatment of various types of cancer?

A: We would be unlikely to abbreviate echocardiography (or any related term, such as echocardiogram) to ECHO or echo. We would spell this term out. Only in cases in which there are serious space constraints would we consider abbreviating this term (eg, in a large table), and then we would recommend expanding the abbreviation in a table footnote.

Q: Do you use Web site or website? Traditionally it has always been “Web site,” but in the past few years I have noticed a change to the more informal “website” in many publications. What is your recommendation?

A: On the home page of the AMA Manual, in the navigation bar, there’s a listing for “Updates.” If you take a look there, you’ll see that a relatively recent update (January 18, 2012) indicates that, as of that date, we began to prefer website to Web site.  Check “Updates” periodically to see if there are other, newer updates on material in the manual.

Q: I have a style question I cannot find addressed in your manual. On a manuscript I plan to submit to a journal, the corresponding author has moved since the manuscript was written and this author wants to indicate both her current and her former affiliation. Can you advise on how to phrase this information?

A: The answer to your question is in section 2.3.3 of the manual. See the relevant excerpt below:

The affiliation listed, including departmental affiliation if appropriate, should reflect the author’s institutional affiliation at the time the work was done. If the author has since moved, the current affiliation also should be provided.

Author Affiliations: Department of Health Policy and Management, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland. Dr Lloyd is now with the Department of Emergency Medicine, St Luke’s Hospital, Milwaukee, Wisconsin.

Cheryl Iverson, MA

Quiz Bowl: To Capitalize or Not to Capitalize

Flipping through the table of contents of the most recent issues of JAMA and the Archives journals, I realize how challenging it can be to correctly capitalize article titles and subtitles. Do hyphenated compounds use initial capital letters on both terms? Are words of 2 letters or fewer capitalized? How do you capitalize genus and species names? Much like Hamlet’s “To Be or Not to Be” conundrum, I am often found muttering to myself “To Capitalize or Not to Capitalize.”

This month in the Archives of Internal Medicine, an article on hip fracture and increased short-term but not long-term mortality in healthy older women appears. But how should this be capitalized as a title? Is it “Hip Fracture and Increased Short-Term But Not Long-Term Mortality in Healthy Older Women,” “Hip Fracture and Increased Short-term But Not Long-term Mortality in Healthy Older Women,” or “Hip Fracture and Increased Short-term but Not Long-term Mortality in Healthy Older Women”?

This month’s JAMA contains an article on the need for critical reappraisal of intra-aortic balloon counterpulsation. But is it the “Need for Critical Reappraisal of Intra-Aortic Balloon Counterpulsation” or the “Need for Critical Reappraisal of Intra-aortic Balloon Counterpulsation”?

Finally, in the Archives of Otolaryngology–Head & Neck Surgery, an article on leiomyosarcoma of the head and neck: a population-based analysis is published. But did the authors perform “A Population-Based Study” or “A Population-based Study”?

Capitalizing titles can provide editors with a sea of troubles, which is why we have chosen the topic for this month’s quiz. Test your ability to correctly capitalize the title in the following example. For further explanation of the correct answer, refer to section 10.2 (pp 372-374 in print). Then check out this month’s quiz (which subscribers can find at for more titles and subtitles to capitalize.

tolcapone in patients with parkinson disease: a randomized, double-blind, placebo-controlled trial

Okay, back to the original question—to capitalize or not to capitalize? How did you handle this title and subtitle? Did you know that double-blind and placebo-controlled are treated differently? Here’s the answer (use your mouse to highlight the text box):

Tolcapone in Patients With Parkinson Disease: A Randomized, Double-blind, Placebo-Controlled Trial

The A should be capitalized because it is the first word of the subtitle (§10.2, Titles and Headings, p 372 in print). Double-blind is a hyphenated compound considered a single word (ie, it can be found as a single entry in Webster’s); therefore, blind should not be capitalized. Placebo and controlled are 2 separate terms operating together as a temporary compound; therefore, both parts of the hyphenated compound should be capitalized (§10.2.2, Hyphenated Compounds, pp 373-374 in print).

For the record, those titles I mentioned earlier should be capitalized as follows:

Hip Fracture and Increased Short-term but Not Long-term Mortality in Healthy Older Women
Need for Critical Reappraisal of Intra-aortic Balloon Counterpulsation
Leiomyosarcoma of the Head and Neck: A Population-Based Analysis

If you want more examples to help you solve the puzzle surrounding correct capitalization of titles and subtitles, take the Capitalization of Titles and Subtitles Quiz on the AMA Manual of Style online.—Laura King, MA, ELS

Questions From Users of the Manual

Q: I thought AMA supported putting no space following a symbol such as > (eg, age <18) if, in the expression, the symbol is acting more as a modifier, not as an operator (eg, 3 < 4), in which case the symbol would have a space (AMA specifies a thin space).  If I’m mistaken, I need to make a mental adjustment.

A:  This is addressed in section 21.10.  We recommend thin spaces with such symbols as greater than, less than, equals, etc.  So, a small mental adjustment might be needed as we make no distinction between the 2 uses you describe.

Q: Is it true that AMA style no longer requires an expansion of CI (confidence interval) at first mention?

A: Yes, it’s true.  As of July 27, 2011, as announced on Twitter, we are no longer requiring that CI be expanded at first mention.  This is posted on the style manual Web site in “Updates to the Manual” and soon will have a special icon within the text to indicate that this material has been updated.

Q: Does AMA have a preferred format for telephone numbers?  How about international numbers?

A:   The manual does not address this question specifically (and perhaps it should).  However, if you look in section 25.11, you will see many examples (both from the United States and elsewhere) for presentation of telephone numbers.—Cheryl Iverson, MA


Questions From Users of the Manual

Q:    When a bulleted list is introduced by a brief comment, eg, “The principal signs and symptoms of rheumatoid arthritis are as follows,” and all of the items in the bulleted list are from the same source, does a citation need to be placed at the end of each bulleted item or is it sufficient to place the citation at the end of the brief introductory comment?

A:    We would recommend placing the citation within the text that introduces the bulleted list if all the items in the list came from the same source.  If the items came from multiple sources, then placing the appropriate citation at the end of each item would be necessary.

Q:    In this example, would you hyphenate “well child”?

  • He was taken for a well-child [or well child] checkup.

A:    Yes, we would hyphenate in this case.

Q:    The Manual says nothing about how to treat reference citations in the abstract.  Should such citations simply be deleted from the abstract and from the reference list or should complete bibliographic details about the reference be inserted in the abstract parenthetically?

A:    You are quite right that the Manual does not mention how to treat references in the abstract as we never include reference citations (either as superscript numbers or within parentheses in the text) in the abstract (see 2.3, fourth bullet, re not citing references in an abstract).  If an author has included references in an abstract, it doesn’t seem advisable to delete the references altogether.  Discuss with the author trying to include the references early on in the manuscript itself.  It seems unlikely that an author would consider a reference important enough to include in the abstract and then not cite it in the text.

Q:   I don’t see anything in the Manual about how to style “e-mail,” ie, with or without a hyphen.  Help, please.

A:   Although the Manual doesn’t specifically address this point, it does include guidance on capping (see 10.7) and, in that section, it’s clear that the Manual recommends a hyphen in “e-mail.”  If you use the Manual online, for questions like this the “quick search” box is invaluable.  Just type the term you are looking for into the search box and the results should guide you.  If you had begun with “email,” you would have gotten no results, which would—I hope—have tipped you off to try “e-mail,” which produces 3 pages of results.—Cheryl Iverson, MA

Quiz Bowl: Units of Measure

Welcome, participants, to the AMA Manual of Style Quiz Bowl. Every month at, we offer subscribers a quiz on different aspects of the manual that help participants master AMA style and improve their editing skills. Previous quizzes have covered topics as varied as correct and preferred usage, genetics, tables, figures, and ethics, as well as numerous other subjects. In this blog, we will offer a sample question from each month’s quiz to whet your appetite. This month’s quiz is on Units of Measure: Format, Style, and Punctuation. So, here goes.

Edit the following sentence based on your understanding of section 18.3 of the AMA Manual of Style.

A total of 50 mg of etanercept were administered subcutaneously twice weekly for 12 weeks.

Well, how did you do? Did you identify the problem? Here’s the answer (use your mouse to highlight the text box):

A total of 50 mg of etanercept was administered subcutaneously twice weekly for 12 weeks.

Units of measure are treated as collective singular (not plural) nouns and require a singular verb (§18.3.3, Subject-Verb Agreement, p 791 in print).

So, did you enjoy this tidbit? If you are not sated, subscribe to the AMA Manual of Style online and take the full quiz.—Laura King, MA, ELS


In everyday usage, apostrophe denotes the punctuation mark used to form the possessive case of nouns, to form possessive adjectives, to indicate the omission of one or more letters in a contraction, and to form plurals of such items as letters, signs, or symbols. Simple, yes? Apparently not. Incorrect use of this seemingly innocuous little jot has become rampant. For example, writers frequently confuse the contraction “it’s” with the possessive “its” — it seems that users of the apostrophe have lost sight of it’s proper use, and its so sad. Another example is when writers use the apostrophe to form the plural of a noun — a usage termed the greengrocer’s apostrophe, presumably owing to its prevalence at one time in grocery signage advertising sale prices on, for example, apple’s, banana’s, and orange’s. While the rise of edited, corporation-issued supermarket signage has rendered use of the greengrocer’s apostrophe more rare in that context than it once was, it now enjoys a wide popularity in other written materials, most noticeably in do-it-yourself advertising copy hawking everything from car’s to hot dog’s to stereo’s — a burgeoning phenomenon that has given rise to another term, apostrophitis.

Apart from this everyday denotation, apostrophe also denotes a rhetorical figure of speech in which a speaker or writer suddenly breaks off narration to direct speech elsewhere, often to exclaim or to convey heightened emotion — as, for example, when a driver conversing with a passenger suddenly breaks into an impassioned aside directed to a recalcitrant automobile, a pedestrian, or the driver of another vehicle. In its original usage, an apostrophe was directed to a person present. However, over time, the meaning has broadened to include speech directed to a person or persons either present, absent, or deceased; to a personified material object; or to an idea or other abstract quality. In poetry or narrative prose, an apostrophe often begins with the word “O”: “O Romeo, Romeo! wherefore art thou Romeo?” (William Shakespeare, Romeo and Juliet, II.2); “O eloquent, just, and mighty Death!” (Sir Walter Raleigh, A Historie of the World). — Phil Sefton, ELS

See 8.7.2 (page 362 in the print book).