usage

Illicit, Elicit, Solicit

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“I am the offspring of illicit love.”1(p814)

“Only suffering… can elicit the perfumes of the soul.”1(p503)

“Henry had been soliciting the pope for some time, in order to obtain a divorce from Catherine of Aragon, his queen.”1(p1822)

Illicit, elicit, solicit. The above examples make it abundantly clear that these words have distinctly different denotations; yet they are often confused or misused, even by careful writers. In medical contexts, it is especially important to preserve the distinctions between them.

Illicit, denoting simply “not permitted; unlawful”2(p618) (and sometimes used colloquially to indicate naughty, unseemly, or immoral), has limited use in medical writing. For example, written materials might convey the risks associated with use of illicit drugs, discuss illicit relationships between researchers and industry, or report on the illicit trade in human body parts. Beyond such instances, however, the word does not often come into play.

Elicit, however, is another story. Denoting “to call forth or draw out (as information or a response)” or “to draw forth or bring out (something latent or potential),”2(p404) the word occurs frequently in medical contexts. It might be used in both senses regarding a patient–physician encounter: for example, a physician evaluating a patient’s pain will ask questions to elicit information about the characteristics of the pain (eg, location, nature, duration, exacerbating factors). From the patient’s perspective, that is the easy part, and patients might well wish this were the end of the matter; however, having thus elicited mere information about the patient’s pain, the physician then embarks on maneuvers expressly designed to elicit the real thing. In written materials covering the basic sciences and their clinical applications, elicit is perhaps most frequently used in the second sense noted above. For example,a writer might report that a new vaccine elicits a given immune response, describe pathological mechanisms that elicit organ damage, or present a theory of how a treatment might elicit changes in gene expression.

Even accomplished writers sometimes confuse the homophones illicit and elicit. However, these terms are easily distinguished from each other: illicit is always an adjective, whereas elicit is—in current usage—always a verb. (It also can help to remember that illicit denotes illegal; for the temperance-minded, the illicit distillation of spirits might also come to mind.)

Troublesome as homophones can be, however, sometimes near-homophones can be more so, especially when they are similar in meaning. For example, elicit and solicit—the latter most frequently used in medical contexts in the sense of “to approach with a request or plea”2(p1187)—are often used interchangeably, with solicit perhaps more frequently used in place of elicit.3 However, such use obscures an important distinction. The Oxford Dictionary of American Usage and Style perhaps explains this distinction most succinctly: “To solicit a response is to request it. To elicit a response is to get it.”3 Thus, in the patient–physician encounter alluded to above, the physician solicits information regarding the patient’s pain and then performs a physical examination to elicit and evaluate actual pain. The Oxford resource also points out an ambiguity that can arise when elicit and solicit are confused: “‘Sentient representatives expect the core group to solicit [read elicit?] response from about 4,000 people.’”3 In other words, will the group solicit responses from 4000 persons, or will the group approach a larger number of persons to try and elicit 4000 responses, knowing that some persons approached might not reply? In medical contexts, the distinction has obvious implications for reports of survey studies and possibly for discussions of power calculations in reports of clinical trials.

Three quick tips:

* Looking for an adjective to describe something as immoral, forbidden, or illegal? Illicit (think illicit = illegal) might be the ticket.

* Looking for a verb to convey the requesting of information? Consider solicit.

* Looking for a verb to convey the obtaining of information or the drawing forth of a response or change? Consider elicit (think elicit = get).—Phil Sefton, ELS

1. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.

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

3. Garner BA. The Oxford Dictionary of American Usage and Style. New York, NY: Oxford University Press; 2000:309.

Incidence

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In medical contexts, incidence is most often used in its epidemiologic sense, ie, the number of new cases of a disease occurring over a defined period among persons at risk for that disease. When thus used, incidence may be expressed as a percentage (new cases divided by number of persons at risk during the period) or as a rate (number of new cases divided by number of person-years at risk).

Reporting several incidence values in the same sentence can nearly always be accomplished using the singular form (eg, “the incidence of nonfatal myocardial infarction during follow-up was 10% at 6 months, 19% at 12 months, and 26% at 18 months” or “the incidence of clinical stroke decreased significantly, from 7.6 to 5.3 per 1000 person-years in men and from 6.2 to 5.1 per 1000 person-years in women). However, in rare instances, sentence construction may necessitate the use of the plural, which of course is… what, exactly? The understandable urge to simply add an “s” at the end of the word to form the plural results in incidences — a form not found in most dictionaries and a clunker of a word if ever there was one. Writers wishing for a more mellifluous plural sometimes use incidence rates, a valid term but one perhaps best reserved for reporting incidence values expressed as actual rates rather than simple percentages. Moreover, incidences is sometimes used when reporting values either as percentages or as rates, in the latter case missing a valuable opportunity to emphasize that rates rather than percentages are being reported.

Thus, it is perhaps best to use incidences, awkward as it may be, when reporting multiple incidence values as percentages and incidence rates when reporting such values as rates, eg, “at first follow-up, the incidences of falls resulting from frailty, neuromuscular disorders, or improper use of mobility devices were 15% (95% CI, 10%-20%), 12% (95% CI, 7%-17%), and 12% (5%-19%), respectively” or “the incidence rates for falls resulting from frailty, neuromuscular disorders, or improper use of mobility devices were 5.1, 6.3, and 4.6 per person-year, respectively.” Incidentally, these 2 examples report occurrences (falls) rather than diseases or conditions, and so represent 2 instances reporting the incidence of incidents.

To further muddy the waters, incidence is sometimes confused with prevalence, defined as the proportion of persons with a disease at any given time (ie, total number of cases divided by total population). Thus, whereas incidence describes how commonly cases are diagnosed, prevalence describes how widespread the disease already is; on a more personal level, incidence describes one’s risk of developing the disease, whereas prevalence describes the likelihood that one already has it. The confusion between the terms is perhaps attributable to the occasional use of prevalence in place of incidence in the study of rare, chronic diseases for which few newly diagnosed cases are available; however, this circumstance is unusual, and incidence and prevalence should always be distinguished from one another and used appropriately. (See also §20.9, Glossary of Statistical Terms, in the AMA Manual of Style, p 872 in print.)

Whereas prevalence is often used in general contexts to indicate predominance or general acceptance, the circumstances calling for the use of incidence in general contexts are quite few and become fewer still when one takes into account that incidence is often used when incidents (the simple plural of incident) or instance (again denoting an occurrence) would be the better choice. Perhaps incidents or instances was intended but never made it to the page — as is so often the case with homophones and near-homophones, even the careful writer who usually would not confuse incidence, incidents, and instance might one day look back over a hastily typed passage only to see that a wayward incidence has crept in; if the passage is hastily edited to boot, the error might well go unnoticed until the passage is in print and a discerning reader takes pains to point it out in a letter or e-mail. The plural form, incidences, has virtually no use outside of the epidemiologic discussed above, although it has been used to subtly disorienting effect by translators rendering the Kafkaesque works of Russian writer Daniil Kharms (1904-1942) into English, most notably when rendering the 1-word title of Incidences, Kharms’ 1934 collection of absurdist critiques on life in the Soviet Union under Stalin. However, writers who are not political dissidents aiming for absurdist effect — presumably all medical writers — would do well to proofread carefully and often. — Phil Sefton, ELS

Respective

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How much can one trust a curmudgeonly English composition teacher who terrorized his early 20th-century Cornell students? How relevant are his grammatical admonitions today? With little else to support my inclination to remove the word respective or its adverb partner respectively and unite the string of data points with what they modify, I find the barking rules of E. B. White’s college rhetoric teacher William Strunk Jr calming.

Based on White’s description of his teaching style in the introduction of Elements of Style,1 I can assert with some certainty that had Strunk found himself an adjunct English composition instructor today, “lean[ing] forward over his desk, grasp[ing] his coat lapels in his hands, and in a husky, conspiratorial voice, say[ing], ‘Rule Thirteen. Omit needless words! Omit needless words! Omit needless words!’” it might not go over so well with today’s sensitive students. The style of this widely emphatic man who barked writing rules during his lectures lasted a lifetime for White. Now about 100 years later, such barking would likely cause a rush to the dean’s office to do something about this brazen man’s approach to teaching. He would simply not be asked back the next semester because the trend today is for warm-hearted English comp teachers to create a safe environment in which students can write without becoming immobilized by gruff commands. So in as much as the style of teaching would end a career today, should one conclude that Strunk’s rules for writing have become as out of date as his approach to teaching them?

Several months ago, after reading White’s delightful 1972 homage to Strunk, I flipped through some of the commands and came upon a piece of advice that lifted me out of my self-doubt and emboldened me not to give up on eradicating the use of the word respective. Unlike the image of Strunk as confident, I am not so. I am one who will eventually cave on a rule, especially if I’m the only one defending it. For example, the use of healthful over healthy when describing behavior that leads to my good health—I have let it go. If a manuscript comes in describing eating fruit as healthy, I will let it stand and not change it to healthful.

Yet, when I see in almost every article that I edit a string of numbers followed by a list of items each number describes covered by respectively at the end of the sentence, my eyes cross. I become disheartened. As I push back my sleeves to match the experimental treatment groups with the values to describe the efficacy of a treatment, I sometimes wonder whether it is worth the effort to set up the parallel structure and the repletion of words to make the match. I sigh and do it, hoping not to offend the author.

Copyediting is a solitary experience that doesn’t often allow for consensus about the rules because, as they say, much of it is a matter of preference. But when one’s eyes land on a sure-footed confirmation about a problem that niggles and nags almost every day of my work life, I must rejoice, which is exactly what I did when my eyes fell to Strunk’s simple exhortation:

Respective, respectively. These words may usually be omitted with advantage.

My heart leaped. I am not alone! Strunk follows his simple rule with an example that justifies my applying it to scientific editing.

The mile run and the two-mile run were won by Jones and Cummings, respectively.

The mile run was won by Jones, the two-mile run by Cummings.

Look at that. The second example has fewer words.

The true purpose of writing is to be clear and not make the reader work too much. As the attention span of the reader decreases by the second, making them match numbers to words 3 lines down gives the reader little reason to continue. In light of today’s hot-footed race against time, I say Strunk is more relevant now than ever. White was right when he wrote in 1979:

“All through The Element of Style one finds evidences of the author’s deep sympathy for the reader. Will felt that the reader was in serious trouble most of the time, a man floundering in a swamp, and that it was the duty of anyone attempting to write English to drain this swamp quickly and get his man up on dry ground, or at least throw him a rope.”

—Beverly Stewart, MSJ

1. Strunk W Jr, White EB. Elements of Style, 2nd ed. New York, New York: Macmillan Publishing Co; 1972.

Envy, Jealousy

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Words that convey similar meanings sometimes come to be used interchangeably. In the case of envy/envious and jealousy/jealous, though, the move seems to have been in one direction only; jealousy is often used in place of envy (“I’m so jealous of your new job”) but not vice-versa (one does not write, for example, “He was poisoned by his envious wife.”). Theodore Bernstein further points out that jealousy is sometimes used, not merely in place of envy, but as a stronger form: “‘There, within a stone’s throw of the sea, he makes his home, and his description of how he does this makes one move from envy to downright jealousy.’”1 A human, and perhaps all-too-familiar, state of affairs—anyone who denies having experienced such a progression of emotion is either hopelessly out of touch with his or her feelings or a liar.

However, although jealous has been used in place of envious since the late 1300s2 and using jealous as a more intense form of envious creates no confusion, it is often held that the words have distinct meanings and that this distinction should be maintained. Even authorities sometimes flounder around a bit when trying to nail the distinction,3 but in general envy is taken to convey a coveting of the wealth, possessions, or success of someone else,4 whereas jealousy is often taken to convey a state of “intolerance of a rival for the possession of a thing which one regards as peculiarly one’s own or for the winning of which one has set one’s heart….”4 Jealousy also can be used in a less grasping sense to indicate the understandable guarding of some possession or attribute, as in “new colonies were jealous of their new independence.”5 Both of the latter meanings highlight that jealousy concerns an attitude toward something that one has or believes one has. In this sense, envious and jealous are not interchangeable—one can jealously guard something, but one cannot enviously guard something.

However, jealous also often carries a frank note of hostility, “a strong implication of distrust, suspicion, enviousness, or sometimes anger.4 This might suggest why the person seeking a word with a bit more heft than envious will sometimes use jealous instead—quite simply, when casting about for a suitably malicious word in the heat of the moment, jealous is low-hanging fruit.

On the other hand, envy is not the innocuous little milquetoast that it at first seems. True, it can be used without malice; one can say, for example, “I don’t envy him his mother in law.” Equally true, it has in the past been used in a noble sense—Aristotle wrote of “good envy,” an admiration that drives one to emulate another3—although that usage has been rare since the 1600s and is now nearly obsolete.6 Certainly, envy carries less emotional charge than jealousy. But to assume that envy is simply a meek cousin of jealousy is to make a mistake.

If jealousy implies strong emotion that often is perhaps all too apparent to everyone involved, envy can imply something more clandestine; as Joseph Epstein puts it, “Malice that cannot speak its name, cold-blooded but secret hostility, impotent desire, hidden rancor, and spite all cluster at the center of envy.”3 Used in this sense, envy suddenly becomes a different animal altogether, and, as Epstein further points out, “The openness changes the nature of the game. Envy is almost never out in the open; it is secretive, plotting, behind the scenes.”3 Perhaps this is another reason that jealousy is often used, albeit subconsciously, in place of envy—after all, envy is one of the Seven Deadly Sins; jealousy is not.

In short, although envy and jealousy have long been used interchangeably and jealousy has come to be frequently used in place of envy, the words do denote different states, and the careful writer should take care to maintain the distinction between them. Both can be used in neutral ways (“She was jealous of her honor”; “I don’t envy him his workload”), but both also can carry weightier meanings; in choosing between them, one might keep in mind that “The real distinction is that one is jealous of what one has, envious of what other people have.”3

The bottom line:

● Looking for a word that expresses the coveting of what someone else has? Use envy.

● Looking for a word that expresses the guarding of what one has or believes one has? Use jealousy.

● Keep in mind that although jealousy is often used as a more intense form of envy, it might be better to use another word or to reword the sentence so as to retain envy.—Phil Sefton, ELS

 

1. Envy, jealousy. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:166-167.

2. Jealous. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:892.

3. Epstein J. The green-eyed monster: envy is nothing to be jealous of. Washington Monthly website. http://www.washingtonmonthly.com/features/2003/0307.epstein.html. July/August 2003. Accessed December 13, 2011.

4. Envious, jealous. Merriam-Webster’s Dictionary of Synonyms. Springfield, MA; Merriam-Webster Inc; 1984:295.

5. Jealous. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:671.

6. Envy. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:523.

Free-range Verbs

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“Patients in the intervention group received doses of study drug in the range of 80 to 325 mg.”

“Patients in the intervention group received doses of study drug ranging from 80 to 325 mg.”

Both of these sentences use forms of the verb range in the sense of “to change or differ within limits”1 or “to vary between certain limits; to form a varying set or series.”2 And both use the word correctly, yes?

The answer would at first seem to be a firm “perhaps.” Some language purists might suggest that range is a verb (at least when so used), and it is not possible for doses and other inanimate subjects to “range.” In this view, the second sentence above would be incorrect. On the other hand, the use of range with inanimate subjects seems quite widespread in everyday speech and writing (eg, “prices ranging from $1 to $15”; “topics ranging from A to Z”). So is this a case of language purists insisting on a distinction that has long since begun to evaporate or yet another case of language becoming more permissive with time?

When attempting to formulate an answer to this question, at least 3 concepts might come into play. First, it is important to note that, unlike some languages such as Japanese3 and the American Indian language Ojibwe (Anishinaabemowin),4 which have different verb forms for use with animate and inanimate subjects, English makes no such distinction. So perhaps those who insist that verbs may be used only with animate subjects are taking their cue from the grammars of other languages with which they might be familiar.

Second, English does distinguish between animate and inanimate subjects when it comes to selecting relative pronouns—who is used with animate subjects (eg, “Patients who received the study drug….”); that is used with groups or inanimate subjects (eg, “The group that best responded….”; “The drug that was administered first….”). Setting aside the questions of whether that constructions are always necessary in such sentences (“The drug administered first….”) and also of whether who should be used only when the subject is human and that used when the subject is nonhuman but animate, it seems possible that a distinction maintained for one part of speech has been analogously applied to another.

Third, there is some precedent in English for avoiding the possessive with inanimate subjects, although that precedent has been on the wane for some time. As early as 1965, Theodore Bernstein quoted American grammarian George O. Curme as saying that, to take the possessive, “‘the [subject] must usually have some sort of individual life like a living being, but this idea of life may be very faint. It is faintest when the name of a thing is used as the subject of a gerund, where it is often not felt at all.’”5 In his discussion Bernstein cites such common examples as “death’s door,” “sun’s warmth,” “ship’s propeller,” and “storm’s fury”; he further notes that inanimate subjects may take the possessive when poetic effect is desired, citing as examples “April’s breeze” and “river’s trembling edge.” However, Bernstein does also point out that the use of the possessive with inanimate subjects is a throwback to previously accepted usage: “Undoubtedly we are witnessing these days a reversion in part from the prepositional genitive—the specialty of the day—to the simple ‘s’ genitive of the older days—the day’s specialty.” So again, it seems entirely possible that over time a distinction maintained for one part of speech might have come to be analogously applied to another; moreover, if that is the case, the new distinction (verbs should be used only with animate subjects) seems to have been based on a distinction (only animate subjects can take the possessive) that superseded earlier usage (animate and inanimate subjects can both take the possessive) but that is once again in decline.

Certainly the use of verbs such as range with inanimate subjects has been accepted since at least the 1830s.2 When David Livingstone wrote in 1857 that “The thermometer early in the mornings ranged from 42° to 52°,”2 he surely meant that the temperature varied between those limits—but he nevertheless was using range in a manner already accepted and considered correct. In a discussion of which prepositions best follow range, Webster’s Dictionary of English Usage cites an example from 1973: “‘…ranging from a whisper to a bray.’”6 (Incidentally, it is pointed out in that same discussion that while Bernstein states that range should be followed only by the prepositions through, with, along, or between, in actual usage range is most commonly followed by from.) More recently still, the 10th edition of the AMA Manual of Style provides, in a discussion of an unrelated point, the example “The percentage of patients who reported gastrointestinal symptoms ranged from 20% to 30%.” (§19.7.2, Percentages, p 831 in print). However, it is worth keeping in mind that when using ranging or ranged with inanimate subjects and describing variation between set limits, those limits should be specified whenever possible (eg, “doses ranging from 80 to 325 mg”) to avoid imprecision.

So free up those verbs, and let those cases, diagnoses, doses, incidence rates, etc, range from X to Y. Just be certain that X and Y are defined when possible, and avoid constructions such as “widely ranging doses” or “incidence rates ranged widely.” —Phil Sefton, ELS

1. Range. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA; Merriam-Webster Inc; 2003:1030.
2. Range. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:1508.
3. More verbs, Japanese grammar and the particle “ni.” All About Teaching English in Japan Web site. http://www.all-about-teaching-english-in-japan.com/Japanesegrammar.html. Accessed January 3, 2012.
4. Anishaabemowin grammar: verbs: transitivity and animacy. University of Wisconsin Letters and Science Learning and Support Services Web site. http://imp.lss.wisc.edu/~jrvalent/AIS/Grammar/InflMorphology/verbTransitivity.html. Accessed January 3, 2012.
5. Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Atheneum; 1965:336-337.
6. Range. Webster’s Dictionary of English Usage. Springfield, MA: Merriam-Webster Inc; 1989:796.

Flaunt, Flout, Vaunt

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Malapropisms: as users of language, we are all guilty of using them sometimes. In the heat of trying to express ourselves, we use one word in place of another—particularly when those words sound similar—and soon we are flaunting accepted usage. Or would that be flouting accepted usage?

To begin with, flaunt relates to vainglorious or ostentatious display, whereas flout denotes an expression of disdain or contempt, often for something forbidden by rule or custom (one grammar blog neatly sums this up by stating that “you flaunt something you like and flout something you don’t”1). Flaunt is used transitively (“Lamilia stopped off to flaunt her ermine and her jewels”) as well as intransitively (“Lamilia came flaunting by, garnished with the jewels whereof she beguiled him”2(p602)) and also is often used in a quasi-transitive sense2(p602) (eg, the currently common “If you’ve got it, flaunt it”). Similarly, flout may be used transitively (eg, the currently common “flout the law”) or intransitively (“It never came into our thoughts… to flout, in so bold a manner”2(p609)). However, flout is not typically used in the quasi-transitive sense.

So flaunt and flout, while often confused, do have distinct meanings. Prescriptive grammarians will point out that flaunt and flout are thus distinct terms and should not be used interchangeably, whereas grammarians with more descriptive leanings will be less inclined to observe a distinction in meaning, in particular maintaining that flaunt may sometimes be used when prescriptive usage would call for flout. Indeed, some authorities, such as Merriam-Webster’s Collegiate Dictionary, now accept the use of flaunt in place of flout in certain constructions—specifically, when the transitive is required (“meting out punishment to the occasional mavericks who operate rigged games, tolerate rowdyism, or otherwise flaunt the law”3). However, at least in relation to this pair of words, the prescriptivists would seem to hold the upper hand. First, flaunt is acceptable (from a descriptive standpoint) in place of flout only when the transitive is required. Second, flout is rarely used in place of flaunt. Third and most importantly, flaunt and flout are similar only in the way they sound, rather than in their (until recently) accepted meanings.

To further complicate matters, though, flaunt is sometimes—albeit quite rarely—confused with vaunt, which denotes boasting or bragging. Like the former, vaunt may be used transitively (“He vaunts his Conquest, She conceals Her Shame”2(p2217)) or intransitively (“They laud their verses, they boast, they vaunt, they jest”2(p2217)) and as early as the 1600s was used in a quasi-transitive sense (“to vant it or vie in gaming”2(p2217)). However, the confusion between flaunt and vaunt stems not only from their marked similarity in sound but also from their somewhat similar meanings (to display oneself boastfully or ostentatiously, often so as to show off one’s attractiveness or possessions, compared with using language boastfully, often to boast of an accomplishment). Indeed, given the similarities in sound and meaning that exist between these two words, it is perhaps surprising that they are not confused more often. On the whole, however, language users usually seem to recognize the difference between these words, and even descriptive usage does not yet support the use of vaunt in place of flaunt or vice versa.

In short, flaunt, flout, and vaunt are sometimes used as malapropisms for one another, particularly in spoken language. However, these terms have distinct meanings and, despite their similarity in sound as well as the increasing support in some circles for sometimes using flaunt in place of flout, currently it is preferable to maintain the distinctions between these terms and to use them as they have predominantly been used over time. Or, to take some liberties with the quasi-transitive:

If you’ve got it, flaunt it;

If you did it, vaunt it;

If they forbid it, flout it.—Phil Sefton, ELS

1. Motivated Grammar: Flout good taste; flaunt your excesses. http://motivatedgrammar.wordpress.com/2008/02/23/flout-good-taste-flaunt-your-excess/. Accessed November 30, 2011.
2. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.
3. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA; Merriam-Webster Inc; 2003:477.

Condition, Disease, Disorder

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“Disease often fortifies the system against the action of remedies.”

“Disorder often fortifies the system against the action of remedies.”

Which of these sentences is correct? As it happens, the first is an actual quote (H. C. Wood, 1879)1(p445) and so in that sense is the “correct” one. However, the question remains: What are the differences, if any, between disease and disorder? For that matter, where does the often-used condition fit in? While these terms are frequently used interchangeably, differences between them do exist and can assist the person wishing to use them in more specific senses.

Condition is perhaps the least specific, often denoting states of health considered normal or healthy but nevertheless posing implications for the provision of health care (eg, pregnancy). The term might also be used to indicate grades of health (eg, a patient might be described as in stable, serious, or critical condition). While this term is often used in medical discussions to specifically indicate the presence of pathology or illness, Dorland’s Illustrated Medical Dictionary provides no definition of the term used in this sense. Merriam-Webster’s Collegiate Dictionary, however, defines condition as “a usu. defective state of health,”2(p258) and the Oxford English Dictionary similarly opines that it denotes “[a] state of health, esp. one which is poor or abnormal; a malady or sickness.”1(p309) In lay conversation condition is sometimes used euphemistically when a discreet term is desired for reference to a state of health, either well or ill—for example, delicate condition was once commonly used to refer to either pregnancy or alcoholism. Similarly, condition understood specifically to indicate the presence of pathology or illness is sometimes used as a value-neutral term when a stronger term might not be desirable. When such considerations do not come into play, a condition conferring illness can be further classified as a disease or a disorder.

“He was full of such disease. That he may nought the deth escape” (1393).1(p445)

Disease is often used in a general sense when referring to conditions affecting a physical system (eg, cardiovascular disease) or a part of the body (eg, diseases of the foot). The term also may be used in specific senses—for example, a writer might refer in general terms to neurologic disease or in specific terms to Alzheimer disease. But disease is perhaps most often used when referring to a condition that possesses specific characteristics. In this vein, Merriam-Webster’s defines disease as “a condition of the… body or one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms…”2(p358); the Oxford English Dictionary defines the word similarly but particularly stresses structural change as a cause.1(p445) Dorland’s concurs with these sources but makes clear that the impaired functioning associated with the diseased state may constitute “any deviation from or interruption of the normal structure or function…” and further elaborates that “the etiology, pathology, or prognosis may be unclear or unknown.”3(p535)

“A Fever is the first disorder that affects the Blood and Vessels” (1725).1(p449)

Compared with disease, disorder is less restrictive: Merriam-Webster’s defines it simply as “an abnormal physical or mental condition,”2(p360) a definition with which Dorland’s largely concurs.3(p555) The Oxford English Dictionary emphasizes that disorder involves a disturbance of function but again further stresses structural change, this time in negative terms, stating that disorder is “usually a weaker term than DISEASE, and not implying structural change.”1(p449) This emphasis on functional rather than structural change has been in place since at least the late 1800s, when the Lexicon of Medicine and Allied Sciences stated that disorder is “a term frequently used in medicine to imply functional disturbance, in opposition to manifest structural change.”1(p449) Because disorder, like condition, is relatively value-neutral when compared with disease, it is often used in place of the latter term when a less stigmatizing or less alarming term is desirable—eg, a clinician might at first refer to a patient’s disease as a disorder to reduce the patient’s initial anxiety; similarly, the same patient might initially refer to his or her recently diagnosed disease as a disorder in conversations with family and friends.

In short, what distinguishes condition, disease, and disorder from one another would seem to be their relative emphases on functional change, structural change, presence of signs and symptoms, and, perhaps to a lesser extent, the gravity a writer wishes to convey:

• Condition simply indicates a state of health, whether well or ill; a condition conferring illness might be further classified as a disease or a disorder—however, condition might be used in place of disease or disorder when a value-neutral term is desired.
• Disease denotes a condition characterized by functional impairment, structural change, and the presence of specific signs and symptoms. As an aside, Dorland’s equates the terms illness and sickness with disease; while these are often used to indicate the state or experience of disease, they are also sometimes used as value-neutral alternatives for disease.
• Disorder, in contrast, denotes a condition characterized by functional impairment without structural change and, while certain disorders or categories of disorders might be accompanied by specific signs and symptoms, their presence is not required for a condition to be termed a disorder. Like condition, disorder is sometimes used as a value-neutral term in place of disease.—Phil Sefton, ELS

1. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.
2. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA; Merriam-Webster Inc; 2003.
3. Dorland’s Illustrated Medical Dictionary. 31st ed. Philadelphia, PA: Saunders; 2007.

Cheat Sheet for Abbreviations Style

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Abbreviations are a convenience, a time saver, a space saver, and a way of avoiding the possibility of misspelling words. However, a price can be paid for their use. Abbreviations are sometimes not understood. They can be misread, or are interpreted incorrectly. … The person who uses an abbreviation must take responsibility for making sure that it is properly interpreted.—Neil M. Davis1

Abbreviations are used widely in medical articles, and great care should be taken to provide expansions that define these abbreviations. The AMA Manual of Style includes a straightforward rule regarding the use of abbreviations: Define abbreviations at first mention by providing the expanded term first, followed by the abbreviation in parentheses, and the abbreviation is used thereafter.

But for every rule, there are exceptions.

Some Exceptions:

• Avoid creating abbreviations for terms that are easy to spell out and do not take up a lot of space. For example, it is not advisable to abbreviate “catheter ablation” as “CA” or “immune response” as “IR.” Also, avoid using too many abbreviations in any one article.

• If a term is better known as an abbreviation, provide the abbreviation first with the definition following in parentheses. “The TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling) staining assay was carried out using an apoptosis detection kit.”

• It is inelegant to begin sentences with abbreviations, unless the expansion is so unwieldy that using the abbreviation makes sense. The previous example, TUNEL, also works here. Rather than begin a sentence with the cumbersome expansion, it is acceptable to begin the sentence with the abbreviation TUNEL.

• Abbreviations should not be introduced in headings. If an abbreviation is being used for the first time in a heading, expand the abbreviation in the heading; then, at first mention in the running text after the heading, expand the abbreviation again, with the abbreviation following in parentheses. Use the abbreviation thereafter.

• Some very common abbreviations do not require expanding at first mention, such as AIDS, TNM, UV, and CD-ROM. A complete list of these abbreviations is provided in section 14.11, with those that do not require expansion denoted by an asterisk.

• The efficiency of using an abbreviation is lost if the abbreviation is used only one time, so as a rule of thumb, introduce an abbreviation only if it is used at least 2 or 3 times.

Items of Note:

• Tables, figures, and abstracts are treated as separate items from the text, so abbreviated terms must be reexpanded in each of these items.

• Use the appropriate article (a or an) before an abbreviation according to the sound following the article (eg, a UN resolution, an HMO plan).

• Use a lowercase s (and no apostrophe) when making abbreviations plural (eg, NSAIDs).—Lauren B. Fischer

1. Davis NM. MEDical ABBREViations: 28,000 Conveniences at the Expense of Communication and Safety. 13th ed. Warminster, PA: Neil M Davis Associates; 2007:1.

Masterful, Masterly

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Writers are often taught that masterful and masterly mean different things and to ensure that they are used correctly. Masterful, so such thinking goes, is taken to mean “suggestive of a domineering nature,” or “inclined and [usually] competent to act as master,”1 whereas masterly is used to denote “having the power and skill of a master.”1

However, the use of masterful to mean “skillful” is now widespread; as Bernstein, clearly a proponent of maintaining the distinction, pithily puts it, “masterly is never misused; masterful often is….”2 Moreover, it seems that the distinction has not always been observed. Whereas masterful has been used in the sense of “domineering” since the 1330s,3 it also was used to mean “skillful” as early as 1613.3 And whereas masterly was used in the sense of “skillful” since the mid 1600s,3 it also was used to mean “domineering” as early as the 1530s,3 although that use has been obsolete since the late 18th century.3

In short, both words have been used to indicate “skillful” since roughly the time of King James I of England. However, the idea that writers should distinguish between them is comparatively new1—and such a late addition of a distinction is the reverse of the more common case, in which a distinction between words ceases to hold sway as the language evolves.

The origin of the distinction? Merriam-Websters posits that it was “excogitated by a 20th century pundit”1—this “pundit” apparently none other than Henry Watson Fowler, editor of The Pocket Oxford Dictionary, coeditor of The Concise Oxford Dictionary and The King’s English, and author of A Dictionary of Modern English Usage.4 In the latter work, Fowler established a distinction between masterful and masterly that was taken up by authorities such as Bernstein2 and that continues to be trumpeted to this day.5 Fowler’s reason for introducing the distinction? Masterly has only 1 sense (at least since its use to mean “domineering” became obsolete), so masterful should be limited to a single sense as well.1

However, some also have argued for the use of masterful in place of masterly in adverbial constructions, pointing out that although masterly is properly used as an adverb as well as an adjective, its use as an adverb seems awkward, even incorrect; eg, “He paints masterly.”2 Moreover, masterly, like many words ending in “y,” is what Bernstein (who nevertheless advocates distinguishing between the words) calls a “reluctant” adverb—ie, a word that resists serving as or being turned into an adverb.6 To make matters worse, masterly takes another adverbial form, the admittedly horrid masterlily.

Where does this leave the conscientious writer? Like Fowler, several modern authorities deem the distinction a valuable one5 and often advocate recasting a sentence to allow a more mellifluous use of a reluctant adverb5,6: hence, the sentence “Its wooden gables… showed how masterly they had been carved of old”3 might be recast as “Its wooden gables… showed the masterly manner in which they had been carved of old,” or similar. “A retreat of this kind,” Bernstein maintains, “is better than clumsy bravado.”6

At least one like-minded authority, however, has conceded that the battle to maintain the distinction—whatever its merits—has likely been lost.5 The prevalence of masterful in everyday usage confirms that opinion, receiving further support from the fact that the words have developed in roughly parallel fashion over time.3 Merriam-Websters concurs, maintaining that masterful used in the sense of “skillful” “has continued in reputable use all along; it cannot rationally be called an error.”1 Moreover, it has been suggested that using masterful in its original sense might even confuse readers now accustomed to the use of masterful to mean “skillful.”7

The bottom line:

● Using masterful in place of masterly to mean “skillful”? You’re in good company, and that usage has a long history. However:

● Set on maintaining a distinction between masterful and masterly? You can’t go wrong there, either. True enough, some readers might be confused by the use of masterful in its original sense—but since when do writers shrink from using words correctly to avoid confusion?—Phil Sefton, ELS

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:764.

2. Masterful, masterly. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:269.

3. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:1045.

4. Sheidlower J. Elegant variation and all that. The Atlantic Online Web site. http://www.theatlantic.com/past/docs/issues/96dec/fowler/fowler.htm. December 1996. Accessed September 16, 2011.

5. Masterful, masterly. Good English Rules! Web site. http://www.goodenglishrules.com/masterful_masterly.htm. Accessed September 16, 2011.

6. Adverbs, reluctant. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:27.

7. Masterful vs. masterly. Grammarist Web site. http://www.grammarist.com/usage/masterful-masterly/. Accessed September 16, 2011.

Purposely, Purposefully

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These words sound similar, and over time their meanings have come to overlap somewhat. Generally, however, they are regarded as having different meanings and uses—although the differences are admittedly subtle—and in choosing between them, writers should carefully consider the message they wish to convey.

Purposely—meaning “with a deliberate or express purpose”1 or “intentionally”2—was first on the scene, entering usage in the late 1400s.2 A second meaning, “to good purpose; effectively,” came into use about 100 years later but is now considered obsolete.2

In contrast, purposefully—meaning “full of determination”1—was a relative latecomer, not coming into use until the mid 1800s,2 and is still used in those senses. Over time, though, purposefully also has come to be used interchangeably with purposely in the sense of “intentionally,”2 perhaps because something done with determination is also done intentionally. But of course the reverse is not necessarily true, which suggests that writers should use purposely when referring to intention alone.

To some ears, however, purposely sounds uneducated or incorrect, leading some writers to instead use purposefully in error; moreover, writers simply looking for a more impressive word will also sometimes instead use purposefully—again incorrectly.3 But even when purposefully is the correct choice, writers should take care that their intended meaning is not misconstrued. For example, the statement “On occasion, a clinician might purposely elicit pain” likely simply means that the clinician is intentionally eliciting pain (for the purpose of making a diagnosis). On the other hand, the statement “On occasion, a clinician might purposefully elicit pain” might imply that the clinician is determinedly eliciting pain (again—one can only hope—for the purpose of making a diagnosis). In both instances, careful handling of the context can make clear that the elicitation of pain is a necessary evil in service of a worthy end. For example, simply ending either of the above statements with “to help make a diagnosis” can go a long way toward ensuring that the clinician is not construed as something of a sadist.

The bottom line:

●Is “intentionally” the intended message? Use purposely.

●Is “full of determination” the intended message? Use purposefully.

●In both cases, however, take care to ensure that the context helps readers determine the intended meaning.—Phil Sefton, ELS

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:1011.

2. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:1474.

3. Purposefully, purposely. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:376.