Rosita Maglie

Understanding the
Language of Medicine
 Copyright © MMIX
ARACNE editrice S.r.l.

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1st edition: October 2009

 TABLE OF CONTENTS

13 Preface

15 Introduction

Part I
Understanding the Linguistic Features of English for Medical
Purposes (EMP)

21 I. EMP from a Diachronic Perspective

23 II. EMP from a Synchronic Perspective

23 III. Lexical Features of EMP

23 1. Monoreferentiality vs. Synonymy

25 2. Denotation vs. Connotation
25 2.1. Metaphor: a case of Figure of Speech in EMP
28 3. Precision vs. Imprecision
28 4. Shortness vs. Redundancy

29 IV. Syntactic Features of EMP

29 1. Omission of Phrasal Elements

30 2. Expressive Conciseness and Pre-modification
32 3. Stacked or Compound Nominal Phrases
33 4. Nominalization
35 5. Lexical Density and Period Complexity
36 6. Sentence Length
36 7. Use of Verb Tenses and Modality
38 8. Use of the Passive and Depersonalization

9
10

40 V. Textual Features of EMP

40 1. Anaphoric Reference and Use of Conjunctions

41 2. Theme and Rheme

41 VI. Text genres of EMP

44 1. Manuscript
44 2. Research Article
48 2.1. Title
48 2.2. Abstract
49 2.3. Introduction
51 2.4. Methods and Results
52 2.5. Discussion
53 2.6. References
53 3. Case Report
54 3.1. Title
54 3.2. Introduction
54 3.3. Literature Review
54 3.4. Case History
55 3.5. Physical Examination
55 3.6. Intervention
56 3.7. Outcomes
56 3.8. Discussion
56 3.9. Summary or Concluding Remarks
57 4. Medical Reports
57 4.1. History and Physical Exam
58 4.2. Consultation Report
58 4.3. Radiology Report
58 4.4. Pathology Report
58 4.5. Operative Report
59 4.6. Discharge Summary
60 5. Patient Information Leaflet (PIL)
 11

64 VII. Spoken Medical Discourse

65 1. Interactions with Patients and Families

69 2. Interpreters in the Medical Setting
71 3. Academic Interaction

Part II
Teaching English for Medical Purposes

77 Didactic Consideration

80 I. Understanding Medical Terminology

87 II. Detecting Information from a Manuscript

88 III. Reading Articles

90 IV. Reading a Case Report

90 V. Reading Medical Reports

94 VI. Reading a PIL

96 VII. Producing Spoken EMP

97 Appendix

147 Bibliography
Understanding the Linguistic Features of
English for Medical Purposes
I. EMP from a Diachronic Perspective

Notwithstanding the purpose of this book is not the analysis of the

evolution of Medical English during the centuries, a brief but special
mention should be made of Helsinki group’s works1 investigating this
linguistic variety from a diachronic point of view.
Their studies of Helsinki Corpus of English Texts have provided
concrete evidence of variation within genres of the early periods. For
instance, the corpus shows that umbrella categories like ‘religious
treatises’ or ‘scientific writing’ contain very heterogeneous texts
(Taavitsainen 1993, 1994a).
They start to investigate western science when it was initiated by
the ancient Greek scientists in their search for principles of nature
and, at the same time, for principles of argumentation for presenting
their ideas. New generations of scientists based their studies on texts
written by their predecessors; changes were gradual and took place
within the old framework. The line continues from scholasticism to
empiricism and then to rationalism, and the outline is characterized
by the dichotomy between science which blindly relies on authorities
in contrast to empiricism, on the one hand, and the rationalistic view
on the other hand. Different periods are traditionally connected with
different styles of thinking and decision-making. Styles of thought
change, and the underlying philosophy of science can be verified by
an analysis of language. Scientific conceptions, objects of inquiry,
methods, evaluations, and intellectual commitments are mediated

1
VARIENG is a Centre of Excellence for the Study of Variation, Contacts and Change in
English. It has about 50 members from the Universities of Helsinki and Jyväskylä, and is
funded by these two universities and the Academy of Finland for the period 2006-2011.
VARIENG members study English in its social, regional and discourse contexts. Special
attention is given to the development of the English language from its earliest stages up to its
present-day varieties. VARIENG members focus on empirical research. They compile and
utilize electronic corpora of English, and develop tools and methods for corpus-based and
ethnographic studies. These resources make up an essential part of the VARIENG
infrastructure, and also benefit the research community at large.

21
22 Part I

through language, both as regards the micro-level linguistic features

and the macro-level argumentative structure. The co-occurrence
patterns of various linguistic features make up the text, and an
assessment of textual strategies reveals how knowledge is
communicated. For example, scholastic writing employs prescriptive
phrases, impersonal structures and the passive voice in imitation of
Latin scientific writing, while texts of the Royal Society period are
written as first person narratives with low modality (Taavitsainen
1994b).
The late middle ages in England saw the flowering of scientific
writing in the vernacular2, taking English discourse in new directions
and establishing new textual genres. Medical professionals had
common public goals, intercommunication and participation
mechanisms, genres of communication3, special lexis, and
membership was acquired by a learning process even in the late
medieval and early modern periods. Precise socio-historical facts
about the writers and readers of the earliest texts are, however,
difficult to obtain, but written sources indicate that communication
between experts and lay people on medical matters and issues
pertaining to health was important since the beginning of scientific
writing (Taavitsainen 2001). In their recent book, Irma Taavitsainen
and Paivi Pahta (2004) examine the sociolinguistic causes and effects
of the process of vernacularization, on the basis of the empirical
evidence from manuscripts and a large computerized corpus4. Topics
2
Vernacularization of scientific writings started in the fourteenth century, in the aspiring
intellectual climate and growing national consciousness of Chaucer’s England. Medical
codices of the period are often bi- or trilingual. Transfer from Latin to English can be seen in
some texts very clearly, as in some treatises the language can change in the middle of a
sentence, or between sentences or paragraphs. L. Voigts’ study (1989) of scientific and
medical manuscripts proves this beyond any doubt. Of the 71 entries studied, 10 are in Latin,
37 are bi- or trilingual, either containing treatises in Latin and Middle English or in Latin,
Anglo-Norman and Middle English, and 24 are exclusively in Middle English.
3
The three traditions of writing, i.e. academic, surgical and the remedy-book tradition
have proved important in explaining variation in early English medical writing (e.g.
Taavitsainen and Pahta 1998).
4
The electronic Corpus of Middle English Medical Texts (MEMT) consists of medical
treatises from c.1375 to c.1500. The corpus contains approximately half a million words of
running texts and comprises edited medical texts and early printed books from different
 Teaching English for Medical Purposes 23

covered include scriptorial ‘house-styles’, code-switching, translation

strategies, and transmission processes. Their book, Medical and
Scientific Writing in Late Medieval English (2004), offers important
new insights into vernacularization, and makes a significant
methodological contribution to corpus linguistics5.

II. EMP from a Synchronic Perspective

This section is about to embark on an emotional discovery journey

through the lexical, syntactic and textual features6 of EMP in order to
make the reader aware of the beauty of this specialized language often
criticized for its cryptic and obscure nature.

III. Lexical Features of EMP

According to Romich (2001), “studying medical terminology is like

learning a new language”. At first words look different and complicated.
However, by understanding a few important guidelines, medical
terminology can become interesting and seem like solving a logical puzzle.

traditions of writing. The range is from theoretical treatises transmitting specialized top-level
knowledge through learned surgical and anatomical texts to simple recipes for practical use
and miscellaneous collections bordering on household literature. The texts differ from each
other e.g. in linguistics features indicating involvement and emotionality, such as personal
pronouns, imperative forms, and passive and impersonal constructions, in expressions of
evidentiality and modality, in the use of appositional constructions, and in meta-discursive
practices. MEMT (2005) was compiled by Irma Taavitsainen, Päivi Pahta and Martti Mäkinen
and published on a CD-ROM by John Benjamins. Certainly, it serves the need of linguists as
well as historians of science, philologists and manuscript scholars.
5
The team are working on a book Medical Writing in Early Modern England (eds. Irma
Taavitsainen and Päivi Pahta, Cambridge: Cambridge University Press, forthcoming). Their
previous volume Medical and Scientific Writing in Late Medieval English (eds. Irma
Taavitsainen and Päivi Pahta 2004) was based on the corpus of MEMT (2005). The new book
will be based on the corpus of Early Modern English Medical Texts 1500-1700 (forthcoming
in 2009).
6
The analysis of lexical, syntactic and textual features of EMP follows the framework
used by Gotti (1991, 2003) to investigate specialized discourse.
24 Part I

EMP is composed of vocabulary of classical (Greek and Latin)

origin, e.g. in vivo, in vitro, deficit, herpes simplex, kyphosis dorsalis
juvenilis7 – from Greek: e.g. phleb-, phlebo- (i.e. phlebitis,
phlebotrombosis); from Latin: e.g. ven-, veno- (i.e. venesection,
venoatrial)8 (Webber 1996:17)9 and vocabulary of Germanic
(Anglo-Saxon) origin, e.g., blister, bruise, graze, freckle, birthmark,
chilblains etc. The spelling of medical terms is really crucial. The
words ileum (i.e. part of the small intestine) and ilium (i.e. part of the
pelvic bone) (Chabner 1991:3-7) are homophones but their actual
meaning is clear when they are embedded in the context.

1. Monoreferentiality vs. Synonymy

EMP vocabulary is characterized by monoreferentiality or

semantic univocity. This implies that in medical language there is
only one word for a specific meaning and concept. The term cannot be
suitably replaced by a synonym but, rather, by a periphrasis, e.g.
hepatitis or inflammation of the liver, due usually to viral infection but
sometimes to toxic agents.
But in EMP there are also occurrences of synonyms, e.g. there are
several expressions which refer to megacolon which is known as
Hirschsprung disease by the Danes, whereas as Ruysch disease by the
Dutch.

7
The examples are provided by the author. But some of them are taken from Webber
(1996) and Gotti (2003).
8
Janet Romich’s article (2001) briefly illustrates the morphology of medical terms,
providing some abbreviated list of medical suffixes, prefixes, and roots, as well as a couple of
examples of morphological rules combining these forms. Learning some basics of medical
terminology could be useful not only for medical personnel, but also for their patients,
especially if those patients want to do more extending reading on medical topics. The
morphological approach to learning medical terms – she states – can be helpful for someone
who must learn many vocabulary terms. But that type of approach must be used cautiously
since the meaning that results from the combination of a given set of morphemes is not
always transparent or predictable.
9
Most medical terminology has Latin/Greek-based words with English lexicalization:
• headache, cephalgia, cephalgic;
• tooth, dens, dentis, dental, dente.
 Teaching English for Medical Purposes 25

2. Denotation vs. Connotation

Denotation (i.e. the medical term possesses one precise literal

meaning) is another characteristic that typifies EMP. When brain is
used in this domain it refers to the organ inside your head (e.g. her
father died of a brain tumour) whereas in standard English it can
acquire a connotative value (e.g. they were not the only ones to have
brains and ambition).
However, in EMP there is a wide use of words or phrases that
depart from straightforward literal language, i.e. figures of speech, e.g.
catachresis (i.e. it expands a word beyond the limits of its own
meaning) (e.g. neck of uterus– corpus/body of uterus– fundus uteri);
ellipsis (i.e. it lacks an element that is, nevertheless, recoverable or
inferable from the context) (e.g. Otto’s fever, parachute mitral valve);
eponym (i.e. it is a person, whether real or fictitious, after whom a
particular place, era, discovery, or other item is named or thought to
be named) (e.g. Parkinson’s disease – Alzheimer’s disease); toponym
(i.e. it is a name of a physical or mental disorder derived from a place
or a region) (e.g. Thogoto virus, Rio Bravo Fever).

2.1. Metaphor: A case of Figure of Speech in EMP

The constant development of science entails a continuous lexical

expansion. As a result, to frame new scientific concepts medical
English increases its vocabulary with borrowings from other
languages, other registers, other branches as well as from everyday
experience. In scientific discourse, metaphorical items may also be
considered a special form of borrowings from different areas which,
once they become part of the specialized language of the discourse
community, are eventually accepted as standard terms10. Salager-

10
Medical discourse uses not only metaphors but also idioms. Since idioms are so
culture-specific, one may wonder why they are used at all in a variety of English which is for
an international audience. In fact, in the average text they are not used frequently, accounting
for only about 1% of the text. They are characteristically found in sections of text expressing
the author’s opinion. This confirms that even scientific communication cannot be divorced
entirely from the author’s cultural background, and indeed that a completely neutral and
aseptic style would be impossible (Webber 1996:42).
26 Part I

Meyer terms these lexical borrowings called for by the development

of new techniques bold metaphor since their stylistic colouring fades
away in the course of time and usage. An example is screening which
is the most frequent word in Webber’s corpus11. After analysing how
the word is used in her corpus she wonders why in science it is used
with the meaning of “the examination of a group of usually
asymptomatic individuals to detect those with a high probability of
having a given disease, typically by means of an inexpensive
diagnostic test’ (Stedman’s 2000:1608). Consulting the Oxford
Dictionary (OALD) she found in the fifth and sixth place the
congruent or literal sense from which the verbal form has been
derived and which fits the epidemiological sense used to denote a
procedure in the study of diseases in populations, namely,

5. “frame with fine wire netting” doorscreen etc.

6. “large siege or riddle used for separating coal, gravel etc. into
different sizes by passing it through holes of different sizes”.

In her article, Webber (1996a) also raises the problem that in the
language of science, non-English native readers may not understand
newly coined terms having metaphorical status. Hence the use of
metaphor described by Levinson (1983) as a term which facilitates
comprehension of complex domains may not work for non-native
speakers.
Following Levinson, Rijin-van Tongeren (1997) sees metaphorical
expressions in medical texts as serving not only didactic but also
catachretic and theory-constitutive functions. The first two are
applied to objects or phenomena that are already known. Didactic
metaphors explain new concepts by means of familiar concepts, e.g.
the transcription machinery of m[essenger] RNA, instantiating both
“the body is a machine” and “a genome is a text”. Catachretic
metaphors fill gaps in a vocabulary, e.g. the “blood vessels as rivers”
metaphor, instantiating the conceptual metaphor “anatomy is a
11
Webber’s corpus used for her study consists of abstracts of research articles or case
reports (size: 100,000 words) collected from two scientific journals: International Review of
Paediatric Otorhinolaryngology, from MEDLINE and Journal of the American College of
Cardiology, available on CD-ROM.
 Teaching English for Medical Purposes 27

landscape”. Theory-constitutive metaphors, on the other hand, are

applied to phenomena that are not yet known in order to structure
them and find out what they are “like”.

In her in-depth article entitled Language and Medicine, Fleischman

(2001) looks not only at (a) the use of metaphors in medicine but also
(b) metaphors generated by body parts and their afflictions and at (c)
metaphors medicine has “exported”.

(a) She analyses a dominant conceptual metaphor of biomedicine:

“medicine is a war” which has long informed the thinking/discourse
about infectious disease (Sontag 1978) and more recently about
cancer, AIDS, and other epidemic diseases (Sontag 1978, 1990; Van
Rijn-van Tongeren 1997; among others). Like all metaphors,
“medicine is a war”, has advantages and drawbacks. While the
imagery of fighting furnishes many patients with motivation,
optimism, and comradeship, it can also contribute to desperation or to
a sense of personal failure if the disease becomes terminal.
(b) She shows how in virtually every language and every culture
body parts serve as metaphors. In English, one needs only think of
expressions such as he hasn’t got a leg to stand on; it makes my blood
boil; she gets under my skin; all based on associative meanings
attached to the respective body parts.
(c) It follows that body illnesses will become metaphors for “the ill
of society”. The illness metaphors that medicine has “exported” are
too numerous to list. Some that come readily to mind are being blind
to reality, deaf to all entreaties; having a lame excuse; an anaemic
economy; or your style is cramped.

To conclude this section, the opinion of Sontag, one the most

thoughtful commentators of medicine’s metaphorical legacy, has been
chosen: “[unfortunately]12 Illness is not a metaphor, and the most
truthful way of regarding illness – and the healthiest way of being ill –
is one most purified of, most resistant to, metaphorical thinking”
(Sontag 1990:3).

12
Word added by the author.
28 Part I

3. Precision vs. Imprecision

Each word can be referred to its concept/meaning immediately

through the analysis of its form thus leading to the phenomena of
precision and transparency. Words can be analysed structurally and
divided into basic components. These components consist of a prefix
(i.e. an affix occurring at the beginning of a word), a root (i.e. the
foundation of a word) and a suffix (i.e. an affix occurring at the end of
a word). For example, the word hyperglycaemia can be divided into
the following parts, e.g. hyper٠glyc٠aemia. The prefix is hyper-, the
root is -glic-, and the suffix is -aemia. After dividing the word into
basic components, the definition can be gleaned by examining the
suffix, followed by the prefix, and then the root(s). If two roots are
present, the word that occurs first in the word is analysed first
(Romich 2001:122-123). In the example of hyperglycaemia, -aemia is
the suffix, meaning blood condition; hyper- is the prefix, meaning
excessive; and -glic- is the root meaning sugar. By putting these
components together, it becomes apparent that hyperglycaemia is a
blood condition of excessive sugar.
On the other hand, in medical discourse there are cases of
imprecision, e.g. the suffix -oma in the term carcinoma (i.e. epithelial
cancer) denotes a very life-threatening disease cancer. But the suffix -
oma in glaucoma does not imply an eye cancer because this disease is
characterized by a rise in the pressure of the eyeball.
In EMP there are also instances of obscurity, namely the use of
specific words instead of current ones; e.g. trichotomy means the
trimming of unwanted hair before a surgery.

4. Shortness vs. Redundancy

Shortness also characterizes EMP. It is used in order to express

several concepts in the shortest lexical and syntactic form, e.g.
urinalysis (i.e. urinoanalysis), contraception (i.e. contraconception);
acronyms13, e.g. HIV (human immunodeficiency virus)/AIDS

13
The reasons for the extensive use of acronyms are (a) the consequence of sublanguage
shaping and use by a relatively closed community and b) efficiency and economicy in use.
 Teaching English for Medical Purposes 29

(acquired immunodeficiency syndrome) – HCV (hepatitis C virus).

Other means of condensing medical terminology are abbreviations
e.g. CV (cardiovascular), Fld (fluid) and stacked noun phrases e.g.
body mass index (BMI). However, there are also examples of
redundancy, e.g. caesarean section delivery where caesarean and
section both imply the cutting of a part of the body.

IV. Syntactic Features of EMP

The atypicality of morpho-syntactic phenomena found in EMP are

not quality-related but quantity-related. At a syntactic level, the main
phenomena are introduced and analysed in the following sections.

1. Omission of Phrasal Elements

Leading to concise/compressed sentences, the omission of phrasal

elements is a common means of communicating most rapidly. It does
not prejudice the understanding of a text as the value of the missing
elements can be re-established by the specialist. This restriction on the
number of words used is not due to the specificity of the subject but to
the linguistic channel chosen to communicate.

Prepositional phrases with of, in, on, with:

e.g. root nodule bacteria (bacteria to be found in root nodules)
Prepositional phrases with for, usually for + gerund:
e.g. the operating room/theatre (the room for carrying out
operations)

Their forms can be:

• simple: NIDDM = non insulin-dependent diabetes mellitus.
• compound: GABAuria = GABA in the urine.
• combined: IgG, IQ 50-70, type A1.

The combined forms can contain numerals and letters for: types, stage, severity, position, and
measures.
30 Part I

2. Expressive Conciseness and Pre-modification

Expressive conciseness and pre-modification are other linguistic

tools which make the sentence more condensed at a syntactic level. In
specialized texts the use of relative clauses is avoided for the sake of
economy and simplicity of the syntactic structure.

Nouns modified by relative clauses:

e.g. a blood donor (a person who donates blood),
e.g. laboratory equipment (equipment which is used in a laboratory)
A combination of passive voice and for + gerund:
e.g. crisis intervention techniques (techniques which are used
for intervening in a crisis)

The first possibility is to replace the relative clause with adjectives,

usually obtained through affixation. The commonly used prefixes and
suffixes have specific semantic values, which allow the decoding of
their communicative function. Some examples of affixations are: e.g.
measurable lesion (lesion which can be measured); reactive force
(force which reacts); absorbent material (material which absorbs).

Another device for simplifying a relative clause is the omission of

subject and auxiliary when the clause has a passive form, as in the
following example:

Patients assigned to the combination-therapy group also

received irinotecan…
(Patients that were assigned to the combination-therapy also
received irinotecan…)

When the verb of the passive form in the relative clause does not
take a complement, it precedes the noun it specifies and becomes a
past participle used with an adjectival function. For example:

Predefined subgroup analyses included analyses of the patients

whose disease progressed after…
(analyses of subgroups which had been predefined included analyses...)
 Teaching English for Medical Purposes 31

When the agent is expressed, it is placed before the past participle

and a hyphen is inserted in between.

Non-treatment-related toxicities
(toxicities which are not related to treatment)

Similarly, the use of the prefix un- before a past participle in

adjectival position permits the omission of the relative clause in the
negative form. For instance:

The unwanted liquid was thrown away

(the liquid which was not wanted was thrown away)

When the verb of the passive form is modified by an adverb, the

latter is placed before the former with a hyphen in between. For instance:

At least one unidimensionally-measurable lesion was required…

(one lesion which can be measured unidimensionally was required..)

Thus and so are used not only in order to avoid a relative clause but
also to coordinate clauses beginning with expressions like and in this
way. In so doing, one of the abovementioned adverbs followed by a
gerund gives more conciseness to the clause, as illustrated by the
following example:

Cetuximab is a chimericIgG1monoclonal antibody that binds to

EGFR with high specificity and with a higher affinity than either
epidermal growth factor (EGF) or transforming growth factor
alpha (TGF-α), thus blocking ligand-induced phosphorylation of
EGFR.

Another device to reduce the complexity of a relative clause is the

use of gerund:

Increasing clinical evidence exists supporting the notion that

radiotherapy dose-escalation results in improved prostate tumor
control.
32 Part I

The aforementioned examples given for the past participle are also
valid for the gerund. For example:

Late-reacting normal tissues

(normal tissues which have a late reaction);
A robot controls the moving line
(a robot controls the line which is moving)

3. Stacked or Compound Nominal Phrases

In scientific research writing, stacked or compound nominal

phrases (NPs) have an above-average incidence (Huckin and Olsen
1983, Salager-Meyer 1984, Williams 1984). Huckin and Olsen (1983)
rightly point out that the use of NPs promotes concise referencing and
discourse cohesion and coherence. In fact, they serve as ad hoc names
for concepts that will be referred to again, thus avoiding long
descriptions. Dubois (1981), in a very interesting article, goes a step
further and suggests that various elements of NPs are generally
rearranged to construct new NPs and that the choice between the two
is not stylistic, but is determined by the writer’s assumptions
concerning shared information on the part of her/his readers14.

14
Dubois illustrates this by taking the following example:

[1] Studies of the oxidative NADP in enzymes in Drosophilla melanogaster have

concentrated on the relationship of gene dosage to the in vitro tissue enzyme level and
on allelozyme variation.

It is possible to rearrange the first NP in the above example in the form of a more complex
nominal phrase by changing post-modification phrases into a more concise pre-modification.

[2] Drosophilla melanogaster oxidative NADP-enzyme studies have concentrated on

the gene dosage to the in vitro tissue enzyme level relationship and on allelozyme
variation.

Dubois (1981) points out that although [2] is more concise, densely packed and hence
space-saving than [1], it is less likely to occur in the beginning of a research article, because,
in that case, the author will be assuming a lot of information on the part of her/his readers
right at the beginning of the article. It appears, therefore, that the scientific writer’s use of
complex NPs is not static but a dynamic one. S/he creates new nominals as s/he goes on
building up new information for the readers.
 Teaching English for Medical Purposes 33

Generally stacked noun phrases are not made up of more than six
nouns. Besides adjectives, the pre-modifying elements of the noun
phrase may consist of nouns, adverbs, participles, hyphenated phrases
or a mixture of these as the following instances show:

antibody-dependent cell-mediated tumor

metastatic androgen-independent prostrate cancer
metformin-associated lactic acidosis
diabetes-related emotional stress
drug injecting behaviour
functional insertion and deletion polymorphism
difficult-to-measure variables

The type of specification may deal with the material of which an

element is made (e.g. osseous tissue, i.e. a tissue of bone-like consistency
and structure), its use (e.g. investing tissue, i.e. a tissue covering or
enclosing a structure), its function (e.g. erectile tissue, i.e. a tissue capable
of erection), and its way of functioning (e.g. dartoic tissue, i.e. a tissue
resembling tunica dartos in its slow involuntary contractions). Very often
stacked noun phrases made up of two short nouns become a single word; at
first they are used in the hyphenated form then they are written as a single
compound word (e.g. juguloomohyoid lymph node, i.e. a lymph node of
the lateral deep cervical group that lies above the intermediate tendon of
the omohyoid muscle and anterior to the internal jugular vein). In order to
decode them it is not sufficient to know the syntactic rules of a language
but mainly to be acquainted with the semantic values of each lemma
making a stacked noun phrase. It must be noted, therefore, that stacked
noun phrases do not necessarily cause problems for the specialist reader.

4. Nominalization

Nominalization15 is another syntactic phenomenon used in

specialized texts16. This process consists in using a noun instead of a
15
Bhatia (1993:148) takes up three major types of nominal expressions. The first type is
complex nominal phrases (Quirk et al. 1982), which is widely used in advertisements of a
particular kind. The second type is known either as nominal compounds (Williams 1984), or
compound nominal phrases (Salager-Meyer 1984), and these are typically associated with
34 Part I

verb in order to express concepts related to actions and practices, e.g.

diagnosis (instead of to diagnose).

The reasons why nominalization is very frequent in EMP are as

follows:

a) in specialized texts, the derivation of a noun from the related

verb appears to reflect the same process of deduction of results from
experiments or the same process of derivation of objects from a
manufacturing process. An example is the following:

Modifications of the dose of cetuximab were made only in

cases of toxic effects to the skin, and modifications in the dose of
irinotecan were made in cases of hematologic or non
hematologic toxic effects.

b) it puts the concept in thematic position, thus making the

communication of information more natural from a condition of new
to already known. In addition nominalization makes it possible to
emphasize the action expressed by the verb by placing it in thematic
position as follows:

Concurrent chemotherapy and radiation has improved the

outcome for patients presenting with locally advanced squamous
cell carcinomas of the head and neck (SCCHS). These
improvements have come at a cost of increased-treatment-
related toxicities.

scientific writing. The third type is conventionally called nominalization, and is

overwhelmingly used in legislative provisions (Bhatia 1983). In the present book the
expression nominalization is used to indicate complex nominal phrases occurring in medical
discourse.
16
Mason (1990) states that nominalization is the major feature of the abstract language
favoured by academic writers in general, and medical writers in particular. This phenomenon
is called grammatical metaphor by Halliday (1994) because it is a device for packing a great
deal of information into fewer words, as processes and properties are reworded as nouns,
while “things” become modifiers.
 Teaching English for Medical Purposes 35

In the second sentence the noun improvements refers to the

rhematic part of the first sentence expanding it and the stacked noun
phrase increased-treatment-related-toxicities refers to the previous
two sentences (non reported for a question of space) cohesively as the
first two sentences deal with adverse effects of chemoradiotherapy.

c) nominalization gives greater objectivity to the author’s thought.

In Halliday’s opinion (1994) “nominalization picks up the preceding
argument and presents it in this ‘objectified’ form as something now
to be taken for granted”. An instance is the following:

The effectiveness of the combination of irinotecan and

cetuximab in patients with irinotecan-refractory tumors suggests
that cetuximab may circumvent irinotecan resistance.

This frequent use of nominalization in medical texts implies as a

consequence a loss of value of the verb. The latter loses its role and
acts as a copula, such that it only links more and more complex
stacked noun phrases. Consequently, there is a higher percentage of
content words compared to the total number of words in a specialized
text. The text becomes denser at the lexical level as the next sentence
shows:

The complete development of the fracture model requires an

understanding of the bond-rupture reaction.

5. Lexical Density and Period Complexity

From the abovementioned instances, we may affirm that EMP is

easier at a structural level and, consequently, that the complexity of
their concepts relies on the syntactic and semantic relationships
established by stacked noun phrases. With regard to the understanding
of a specialized text, even if the structure is simplified, the higher
lexical density of the sentence and the more complex structure of
stacked noun phrases makes its decoding more and more difficult for
non-specialists. This leads to the predominance of main clauses at the
expense of subordinate ones. The period complexity consists in a
36 Part I

specialized period characterized by a great number of non-finite

forms, as the following example shows:

Fifty-six percent of patients received more than 90% of

prescribed amifostine doses, with chemoRT-related toxicity
being the most common reason for withholding the dose (77%).

6. Sentence Length

The length of the sentence is another factor which complicates the

comprehension of a medical text. In fact, these texts are structured in
periods which are longer than those of common language. This habit
is due to the need to include a number of elements so as not to create
an information gap or ambiguity. Here is an example:

In order to improve the positive predictive value (PPV) for cancer,

predictors of biopsy outcome have been investigated including DRE
and TRUS findings and PSA correction methods such as density,
velocity, and age-adjusted reference ranges, but none of them has
proved useful to select cases for biopsy with an acceptable balance in
terms of avoided biopsies versus reduced sensitivity.

7. Use of Verb Tenses and Modality

Salanger-Meyer (1993) has studied the use of tenses in abstracts17.

She has found that the research-type factor is not a discriminating
variable whereas the text-type is. Thus, while the past is predominant
in case reports and research articles, the reverse situation is observed
in review articles, with the predominance of the present tense18.

17
However, her observation probably applies to other sections of the research article – as
abstracts represent the whole text in miniature.
18
Thomas and Hawes (1994) describe the reporting verbs used in reporting statements,
citations, in medical journals and their role in the discourse. The choice correlates with the
rhetorical function of the report in which the verb occurs: Cognition verbs (like believe, hate,
know, like, enjoy, understand, want) with reports of consensus views of the scientific
community; Tentative (Discourse) verbs (such as attempt, desire, expect, plan, try) with the
 Teaching English for Medical Purposes 37

Modals are used much more frequently in review articles (17.9% as

against 7.7% and 4.8% in the other two text types). The modal verb
may has the highest frequency. As regards the different moves within
each text, the past is found overwhelmingly in the results and in the
methods sections (mainly active in the results and passive in the
methods), the present is found predominantly in the conclusions as
well as in the recommendations which commonly appear at the end of
the discussion section. Modals are found above all in the
recommendations, followed by the conclusions and the data synthesis.
In a study on modality in present-day medical writing, Vihla
(1999) has focused on epistemic and deontic modalities, on the
certainty of knowledge and the necessity of acting in a particular way
in four different genres in recent American medical writing: research
articles, editorials, manuals, and popular articles19. Her major finding
is that modality varies according to the function and pragmatic aim of
the genre so that epistemic modality is prominent in research articles,
whereas deontic expressions prevail in manuals20. The former -
epistemic modality - is concerned with the status of the speaker’s
beliefs and corresponding degrees of conviction, whereas the latter -
deontic modality - deals with the speaker’s authority in terms of
granted permission and imposed obligation.
Webber (2001) has analysed modality in face-to-face interactions at
conference and reported that there is a higher incidence of subjective
modalization with I/we think, items that allow speakers to express a
personal opinion with a certain degree of reservation, hence without
being too dogmatic or sure of themselves. Moreover, in conference
discourse there is a great deal of sifting of evidence, separating what is

generalized conclusions of cited studies; and Certainty verbs (like modal verbs or certain other
groups of verbs like doubt, suggest, conclude) with reports of specific results and findings.
19
She has obtained the reported findings by using corpus linguistics methods. In
particular, she compiled a corpus called Medicor containing contemporary medical texts (size
397,311 words).
20
May is the most frequent modal in her corpus. ‘Possibility’ modals (can, could, may,
might) are most frequent in popular and professional directive texts, and ‘necessity’ modals
(must, should) have the highest frequencies in professional directive texts and editorials. The
semantic analysis shows that may and might are usually epistemic, while must and should are
most often deontic. This difference is also indicated by their collocations.
38 Part I

known from what is as yet uncertain in a terrain which still needs to be

explored and mapped out. There is thus even more uncertainty in
Webber’s spoken corpus, with a higher incidence of might than in her
written corpus and a lower incidence of should for recommendations.
The explanations offered for the findings – she states – are even more
tentative and speakers do not feel ready to offer recommendations in
the same way as published articles do.
The ways for expressing modality are different non only in relation
to the genre under study and the channel chosen to communicate
(written or spoken) but also in relation to different periods. In a
diachronic study on medical English, Taavitsainen has demonstrated
that Scholastic writings favour prescriptive impersonal constructions
and the prevailing modality is deontic21, whereas experimental essays
of the Royal Society are written with subjective epistemic
judgement22. This is also shown in the semantic types of verbs that
reveal the strongest associations with modal verbs in two periods. Late
Middle English has mostly action verbs, whereas verbs of mental
processes become more common in Early Modern texts.
In conclusion, the modality of scientific texts is related to changing
ideological foundations, the institutional and disciplinary context of
writing, and the communicative functions of genres within the
scientific register.

8. Use of the Passive and Depersonalization

Finite verb forms have frequencies of use very similar to common

texts, whereas non-finite verb forms occur with double the frequency
in specialized texts in comparison with standard English, due to their

21
During Scholasticism knowledge came from ancient authors: Galen, Aristotle,
Hippocrates and Arab scientists. What they said was indisputable and their name was enough
to guarantee the status of the knowledge.
22
In the Royal Society period, knowledge is not asserted as received, but it is shaped in
the text. In this period, the emphasis shifted from ancient authorities to mental processes and
observations as the source of knowledge. The idea was to present the steps of carrying out the
experiment in detail so that anyone could do the same; even if scientists could not agree on
the causes of nature, consensus could be reached on the processes that could be witnessed by
anyone (Dear 1991:161).
 Teaching English for Medical Purposes 39

ability to make a text condensed and short. But a phenomenon worth

highlighting is the passive voice use23. The frequent use of this form
satisfies the need for the depersonalization of the discourse by the
specialist who is more interested in underlining the effects and results
of an action than in stressing who the author of the action is. It is for
this reason that the agent is seldom expressed. However, scientific
writers do not always prefer impersonal forms. As G. Myers (1989)
shows, speakers use the first person as a politeness strategy, to avoid
face-threatening acts, and this applies to a slightly lesser extent also to
written texts. Hence, expressions such as “we investigated” and “our
findings suggest”, far from being presumptuous may in fact appear
more modest than the corresponding passive or nominalization, which
can give the impression that a statement has universal truth value
(Webber 1998). There are also stative verbal forms expressing not an
action but a condition, a state. Their form is very similar to the passive
form but the past participle has more an adjectival function than a
verbal one. Some examples are as follows:

The system is composed of…

The patients were evaluated…
The data were collected…

Let us analyse another example:

We considered patients eligible if they were more than 18 years

of age and had stage IV, histologically confirmed colorectal
adenocarcinoma. Other criteria for eligibility were used: a
Karnofsky performance-status score of 60 or more; adequate
hematologic function (haemoglobin, at least 9 g per decilitre
[5.6 mmol per liter]; neutrophil count, at least 1500 per cubic
millimetre; and platelet count at least 100,000 per cubic
millimetre.

23
Halliday (1994) has referred to the increasing impersonalization of scientific English
and lists “impersonal style” as one of the characteristics of the syndrome resulting in a
widespread use of the passive in its typical function in English – that is, achieving a balance
of information so that a result or a process is placed in thematic position rather than the actor.
40 Part I

The alternation of active or passive forms cannot be explained in

syntactic terms but it depends on complex factors which are pragmatic
and textual. At first the authors want to underline their contribution,
then they use the passive form to mention the criteria adopted in order
to carry out their study.

V. Textual Features of EMP

There are many features that distinguish medical texts also from the
textual standpoint. Some of these are characteristics shared by all
types of texts but constitute a distinction in quantitative terms.

1. Anaphoric Reference and Use of Conjunctions

Anaphoric reference is a device used to increase textual cohesion.

The reasons for its use depend both on the need for extreme clarity
and the will to remove all types of ambiguity. However, it is less
frequent in specialized texts than in general English: it is normally
avoided in favour of lexical repetition.
The need for precision lies at the base of another relevant feature of
medical texts, that is, the frequent reference to the parts of the text
itself. The function is metatextual - as it refers to the text itself - and
specifies a textual element to which it is referred as clearly as possible
(see the first example). In other words, it modifies past participles
which could otherwise be misunderstood (second example):

In section 21 thereof
The day and the year first above written

Like anaphora, conjunctions have not only a cohesive function but

also a pragmatic one as they show the function of the following
sentence. For example, after but, however, on the other hand the
addressee is prepared for a sentence clashing with the previous one
semantically as the following instance shows:
 Teaching English for Medical Purposes 41

Patients with advanced colorectal cancer who receive

fluoropyrimidine, irinotecan, and oxaliplatin in combination or
sequentially may survive 18 to 21 months. However, once these
three standard drugs have failed, there are no accepted
treatment options.

2. Theme and Rheme

As for the thematic organization of specialized texts, it consists in

alternating thematic parts (where the subject is introduced) and
rhematic ones (showing what is said about the subject)24. Often the
known/given datum is put in the thematic part. The sequence of
thematic and rhematic elements in the sentences assures cohesion and
coherence to a discourse. Here is an example of thematic progression:

(i) The simple linear thematic progression

In the past decade, the median duration of survival among
patients with advanced colorectal cancer has increased from 12
months to about 18 to 21 months, mainly owing to the
introduction of irinotecan and oxaliplatin. Irinotecan and
oxaliplatin are widely used…

VI. Text genres

The variety of writings in the medical profession is large, ranging

from a single one-page information sheet to a research paper containing
multiple pages. The most common types of medical writings are:

24
Kevin Nwogy and Thomas Bloor (1991) investigated the thematic progression in
professional and popular medical texts and their analysis shows that in their corpus only the
research article exploits all the four thematic progression patterns such as (i) the simple linear
thematic progression; (ii) thematic progression with a continuous (constant) theme; (iii)
thematic progression with derived themes; (iv) the split rheme pattern. The journalistic report
version exploits three (no. (iii)), while the abstract features only two (nos. (iii) and (iv)). This
can be explained in terms of the factors of audience, purpose, and context on the organization
of information.
42 Part I

Manuscripts: written or typewritten versions of a book or other

work submitted for publication.
Journal articles: writings on a specific topic that detail background,
methods, results, and conclusions; they usually appear in a newspaper,
journal or magazine. They are divided into original, and review articles.
Editorials and letters to the editor: writings presenting thought-
provoking alternative interpretations and methodological insights25.
They may also give testimony to the wit, good humour, and even
poetic talent of the medical community.
Reviews articles: these focus on content. Their aim is to present a
large amount of information on a subject comprehensively and
efficiently26. Writers of reviews are often acknowledged as experts in
their fields and frequently have conducted research themselves.
Systematic Reviews: these start from a clinically relevant question
and highlight this issue on the basis of findings presented in various
research articles27.
Research papers: investigations into a topic to obtain facts and
theories.
Case-reports28: these are one of the few text genres in medical
journals which tells a story29.

25
Because letters are usually limited to brief reports and preliminary observations, they
rarely include detailed methodology. Nor are letters sent out for peer review, as are more
substantial works of original research.
26
Meyer and Freedle (1975) recognize five different schematic ways in which writers
organize and readers understand topics in expository texts: collection or list, cause and effect,
problem-solution, compare and contrast, description or attribution.
27
Systematic reviews are distributed in electronic format in the Cochrane database of Systematic
Reviews, and instructions on how to write such reviews have been introduced, indicating that the
medical community aims to standardize the conventions of this relatively new genre.
28
According to McCarthy and Reilly (2000) case reports have made a valuable
contribution to the advancement of medical science even before Hippocrates.
29
Papadopoulos (2002) affirms that a case report is generally more interesting than other
forms of scientific communication because the human element adds an appeal that may be
lacking in other research. Moreover Anwar et al. (2003) advise authors to write it in an
interesting manner, which their reader should enjoy.
 Teaching English for Medical Purposes 43

Case-series studies: descriptive studies that can provide data on

the natural history of the disease or offer experience to guide health
services. They can give a first glimpse of exciting new findings or
demonstrate exceptions to the rule.
Case histories: these include information on how the patient’s
condition was noticed and diagnosed, how the condition has been
treated, and how the patient responded to treatment. The “problem-
oriented medical record” favoured by most teaching hospitals today
(Weed 1970) organizes this information into four categories, known as
SOAP: Subjective (the patient’s statement of her/his condition),
Objective (the physician’s observations of the patient’s condition),
Assessment, and Plan.
Reports: formal accounts of proceedings presented in details.
Abstracts: short pieces of writing that clearly summarize larger
works; they cover procedures, results of studies or experiments, and
conclusions.
Value-Added Abstracts: these summarize research articles or
reviews written by someone other than the writer of the abstract. They
introduce briefly the aims, methods, findings, and include a comment
and assessment of the results and their clinical relevance (Vihla 1999:
129-130)30.
Documents: original written or printed pages that provide evidence
or information.
Grant proposals: requests for a sum of money to research into
special projects.
Patient Information Leaflets (PILs): these are highly
conventionalized directive texts aimed at giving practical, objective
instructions31.

30
Systematic reviews and value-added abstracts mirror a practical need, as medical
practitioners may not have time to follow up research done in the various fields of medicine and
to compare findings of individual studies, but still require new information in their work. The
new genres aim at answering this need, distributing information in a compact form (Vihla 1999).
31
In her speech at the First Dublin City University Postgraduate Conference in
Translation Studies (2004), Cacchiani analysed a corpus of 10 British and 10 Italian PILs
from the 1990’s, and 10 recently revised Italian PILs which are supposedly clearer and more
user-friendly in order to underline the significant differences across languages that can be
observed at the structural, syntactic, and semantico-pragmatic levels, primarily motivated by