- Email: [email protected]
English as she is wrote
least partly due to the striking increase of coverage achieved by the national screening programme between 1988 and 1992Y If the falls in mortality in 1993 and 1994 are indeed attributable to screening, then we can expect further substantial falls in 1995 and 1996, and we are well on target to meet the challenge of fewer than 1000 deaths from cervical cancer by the year 2000. *Peter Sasieni, Jack
Cuzick, Elaine Farmery
*Department of Mathematics, Statistics, and Epidemiology, Imperial Cancer Research Fund, PO Box 123, London WC2A 3PX, UK; and Health Commission for Wiltshire and Bath, Devizes, Wiltshire
1 Sasieni, P. Trends
in
cervical
cancer
mortality. Lancet 1991; 338:
818-19.
Department of Health. Cervical cytology 1992-93: summary information from form KC53, England. London: Department of Health (SD2B), 1994. 3 Farmery E, Gray JAM. Report of the first five years of the NHS cervical screening programme. Oxford: National Co-ordinating Network, 1994. 2
Inhaled steroids and psoriasis
Mark Harries St Mark’s NHS Trust, Middlesex HA1 3UJ, UK
cap
polyposis
SiR-Cap polyposis is rare.’-3 We report a patient with cap polyposis who had been treated for ulcerative colitis for 7 years. woman was admitted to our hospital in with May, 1995, suspected osteoporosis. Persistent mucoid diarrhoea started in 1988, and she was diagnosed elsewhere as having ulcerative colitis in 1989. She had been treated with 10 mg oral prednisolone and 40 mg prednisolone enema daily for 10 months, then topical steroids were reduced to 30 mg per day and continued for almost 6 years. Mucoid diarrhoea appeared again several months before she came to our hospital. Serum total protein was 3-9 g/dL and albumin 2-4 g/dL. Serum IgG, IgA, and IgM levels were also decreased (174 mg/dL, 61 mg/dL, and 61 mg/dL). Scintigraphy using 99m technetium-labelled human albumin indicated protein loss from her descending colon. A considerable amount of immunoglobulins was detected in mucous discharge (IgG 102 mg/dL, IgA 69 mg/dL, and IgM 13 mg/dL). Colonoscopy showed sessile polyposis with a remarkable quantity of mucus attached to the surface, from the rectum to the distal descending colon with patchy normal intervening mucosa. Our first impression was of a protein-losing enteropathy with ulcerative colitis; however, the biopsy specimen showed no crypt atrophy and a hyperplastic epithelium with the surface. of the towards infolding epithelium, particularly filled with There was acute cells were mucus. Epithelial The muscularis inflammation mainly towards the surface. mucosae was disrupted and occasional smooth muscle fibres were present in the mucosa. She was diagnosed as having cap polyposis. As mucosal ischaemia has been suggested for the pathogenesis of cap polyposis,2 mucosal blood flow was
54-year-old
*Nobuhide
Oshitani, Yoshinori Moriyama, Takayuki Matsumoto, Kenzo Kobayashi, Atsuo Kitano *Third Department of Internal Medicine, Osaka City University Medical School, Osaka 545, Japan; Department of Internal Medicine, Jyuso Municipal Hospital, Osaka
2
3
Williams GT, Bussey HJR, Morson BC. Inflammatory ’cap’ polyps of the large intestine. Br J Surg 1985; 72 (suppl): S133. Campbell AP, Cobb CA, Chapman RWG, et al. Cap polyposis—an unusual cause of diarrhoea. Gut 1993; 34: 562-64. Géhénot M, Colombel J-F, Wolschies E, et al. Cap polyposis occurring in the postoperative course of pelvic surgery. Gut 1994; 35: 1670-72.
English
as
she is wrote
SiR-Francis Crick has written that "There is no form of more difficult to understand and more tedious to read than the average scientific paper"’ which bears out the argument in your Oct 21 editorial. Having edited three medical or scientific journals over the years, I support your lament about the poor state of written English in most of the medical (and scientific) press. There are several contributory factors, for some of which editors have only themselves to blame. I agree that when they meet, medical editors are much more likely to discuss subjects other than the clarity of the papers that they publish. There are a number of fashionable topics floating around and journalology seems certain to have its own journal before very much longer. The role of the statistician seems to have become overly influential, editors apparently considering that p values and t tests are more descriptive than words. I very much regret that editors are more likely these days to consult Bradford Hill than Fowler (although if they consulted Bradford Hill solely for matters of style, one would have no complaints at all). It is to the statisticians that we owe the awful device of the structured abstract which, as I understand it, was devised to satisfy the requirements of those who only read the abstracts of papers dredged up for them by their computer. We have even had the spectacle of an author decrying the use of "Whimsical titles" which "may leave the readers bewildered about the broad category under which the contents of a paper belong". Readers in this case refers to those who are attempting "partial text electronic coverage".2 If this is the kind of English to which browsing electronic data bases leads, the sooner they are banned, the better. The increased use of computers as a substitute for a trip to the library does nothing to encourage authors to try to express themselves well, but editors might improve the situation if they allowed authors to break free of the IMRAD (Introduction, Methods and Materials, Results, and Discussion) convention in which papers are presented. A more informal style of writing, with the use of the active voice rather than the passive, is likely to allow authors to present their work in a more readable and interesting way, and probably describe the train of events that lead up to the prose
Department of Respiratory Medicine, Northwick Park Hospital, Northwick Park and
A
We thank Dr D P Jewell for clinical advice and Dr B F Warren for histopathological review.
1
SIR-A patient presented with relapse of her psoriasis which had been in remission for a number of years. She attributed this to a change in her asthma medication from budesonide Turbohaler to fluticasone Accuhaler. The budesonide was reinstituted and the psoriasis cleared. Does this observation reflect a difference in the absorption pattern of the two drugs from the lung or does it infer the efficacy of inhaled budesonide as a treatment for psoriasis?
Protein-losing enteropathy from
measured with laser doppler. No difference was noted between the affected and non-affected mucosa. Cap polyposis affects both sexes over a wide age range (17-82 years).’ Aetiology is unknown, although mucosal prolapse and abnormal rectosigmoid motility’2 or infection3 may contribute to the pathological appearances. 1,2 Our patient had constipation for a long time before diarrhoea started. The muscularisation in the biopsy specimen indicated the presence of some degree of mucosal prolapse in this patient. It is suggested that persistent mechanical stimulation due to mucosal prolapse might lead to hyperplasia of the mucosa, leading to hypersecretion of serum proteins into the lumen surface.
1567
in a more realistic way than is possible otherwise. Authors should also be encouraged to use simple language and be as brief as possible; there is almost nothing said in ten pages which cannot better be said in five. And it is astonishing that so many people, who are able to describe their work in a clear, interesting way when talking about it, feel compelled to resort to the pompous verbosity that characterises so much scientific writing. There is much editors can do to raise the standard of written English in their journals. They will need to give much time and effort to it, commodities already in short supply, especially for most part-time editors; they will need to think less of their citation index and more of the duty that they have to their readers, which is to see that their journals not only instruct but also give some pleasure.
publication
H A Waldron, Editor, Annals of Occupational Hygiene, 31 Maidstone Road, London N11 2TR, UK 1
2
Crick F. The astonishing 1995. Kerr JR. Whimsical titles
hypothesis. are
London: Touchstone
deeply unhelpful. BMJ 1995;
Books, 311: 879.
SIR-The difficulties the scholar faces in the pursuit of elegance, the subject of your Oct 21 editorial, are not entirely self-inflicted. Serious journals accept little variation in structure or vocabulary and the papers they carry are highly conventional documents-one convention being that the author(s) assume that note of modest, depersonalised scientific humility which makes an individual voice hard to develop, and another that the structure of the paper should take the fun and suspense out of a good story. The 19th century saw the development of journals which put a premium on one version of stylistic excellence but at least there was space on offer to permit authors to unpackage their wares. Writers could offer a degree of idiosyncrasy. Moreover, a major genre of that era was the chronologically unfolding case study, a story in which the leading actor was the doctor himself-the man whose most basic feature of style was "I did this" and whose aim sometimes seemed to be to tell us how he felt, to share an understanding with readers of what it is to be a doctor. The sweep of the story from the introduction of the patient (with scant regard for confidentiality) as "Charles E May, aged 25, a sergeant in HM 51 regiment ... complained of having been feverish and unwell for some days ..."’ to his mysterious affliction to the denouement (often sadly, post mortem) is reminiscent of another chronologically ordered genre developed in that century, the detective story. Conan Doyle was a doctor; Sergeant May was an opium eater. Modern medical writing has the excitement knocked out of it: "Medical journals", as Asher remarked "are dull".2 For example, convention demands that the chaotic hit and miss of much real experimentation (the questionnaire the cat ate, the missing notes, the dropped test tube) be suppressed in favour of an account of seamless perfection.3 If they are mentioned at all, mistakes and oversights are squeezed into a couple of sentences. This draining of life from the scientific drama is part of the convention of authorial anonymity. In a medical journal today you must, unless you are very famous, present yourself as a humble faceless servant in pursuit of truth. This on occasion may mask a monstrous ego in pursuit of personal advancement, but it does not alter the convention. "I did this" as a means of advancing the logic of the paper is not permissible. We must recognise just how rigorous these conventions are and what a constraint on literary skill they impose. The organising principle of the contemporary medical paper no longer has the simple force of chronology, but undertakes a ritual dance through Introduction, Methods, Results, and
1568
Discussion. The constraints are not fully understood and are covered hardly at all by the International Committee of Medical Journal Editors. The example of "hedging", mentioned in your editorial, is typical. Hedging may indeed be badly deployed in academic papers, but this may simply be that the conventions are not well understood. For example, hedges in the discussion and the introduction will manifest in very different forms. A discussion section will be littered with "may", "perhaps" and the like. By contrast, hedging, as the authors’ way of distancing themselves from the truth value of the propositions they utter, will in the introduction be more commonly realised by the choice of reporting verbs to discuss the work of previous authors. "Smith showed [in her authoritative study]" is at one end of the scale and "Jones suggested [but we all know what a fool he is]" is at the other.’ Stylistic elegance presupposes the mastery of convention. A successful sonnet presupposes knowledge of the rhyme scheme and elegant medical writing presupposes knowledge of conventions no less closely adhered to but poorly described and hardly ever debated. Medical students receive little or no training in writing, and postgraduate "writing courses" are often taught by people with no understanding of linguistic structure or the conventions of the academic article. There are plenty of books for the would-be writer but the advice amounts to little more than vague exhortations to "be clear, be concise". ("Right", said the coach, "today’s tactic-score more goals than they do.") There is a desperate need for a better understanding of what is involved in good academic writing. Good writing and good thinking go hand in hand. John Skelton Department of General Practice, University of Birmingham, Birmingham B15 2TT, UK 1 2
3
4
5
Bowling JP. Abscess of the caecum, containing solid opium, in an opium-eater. BMJ 1853, Feb 18: 150-51. Asher R. Why are medical journals so dull? BMJ 1958; ii: 502-03. Gilbert GM, Mulkay M. Opening Pandora’s box: a sociological analysis of scientific discourse. Cambridge: Cambridge University Press, 1984. Skelton J. Analysis of the structure of original research papers: an aid to writing papers for publication. Br J Gen Pract 1994; 44: 455-59. Thompson G, Ye Yiyun. Evaluation in the reporting verbs used in academic papers. Applied Linguistics 1991; 12: 365-82.
SiR-In your excellent editorial you attacked the decline of the English language into ugliness and obscurity, and put much of the blame on scientists. We all know what you mean. A short time ago, a young British embryologist, working in California, submitted a paper to the university on "Pigment patterns in birds". The paper was accepted but the title was changed to "Pigment patterns in avians". "Why?" asked the author, "they mean exactly the same?" "Yes," replied the editor, "but ’avians’ is more scientific". This kind of pretentiousness and obscurity is not peculiar to scientists. A group of young lawyers, called "Clarity", is dedicated to improving legal language by simplifying it. The Council of Ministers of the European Community has ordered the Commission’s bureaucrats to use clear and simple language when drafting legislation, and told them how to do it. The daily Court Circular, will no longer, we understand, describe ambassadors to the Court of St James’s as being "extraordinary" and "plenipotentiary": they will be merely "ambassadors". Could doctors and scientists not deal with their own professions in the same way-the doctors led by The Lancet maybe? Hippocrates, they might like to remember, was admired for the conciseness of his style.
Eirlys Roberts European Research
into Consumer
Affairs, 8 Lloyd Square, London WC1X 9BA, UK
Cuzick, Elaine Farmery
*Department of Mathematics, Statistics, and Epidemiology, Imperial Cancer Research Fund, PO Box 123, London WC2A 3PX, UK; and Health Commission for Wiltshire and Bath, Devizes, Wiltshire
1 Sasieni, P. Trends
in
cervical
cancer
mortality. Lancet 1991; 338:
818-19.
Department of Health. Cervical cytology 1992-93: summary information from form KC53, England. London: Department of Health (SD2B), 1994. 3 Farmery E, Gray JAM. Report of the first five years of the NHS cervical screening programme. Oxford: National Co-ordinating Network, 1994. 2
Inhaled steroids and psoriasis
Mark Harries St Mark’s NHS Trust, Middlesex HA1 3UJ, UK
cap
polyposis
SiR-Cap polyposis is rare.’-3 We report a patient with cap polyposis who had been treated for ulcerative colitis for 7 years. woman was admitted to our hospital in with May, 1995, suspected osteoporosis. Persistent mucoid diarrhoea started in 1988, and she was diagnosed elsewhere as having ulcerative colitis in 1989. She had been treated with 10 mg oral prednisolone and 40 mg prednisolone enema daily for 10 months, then topical steroids were reduced to 30 mg per day and continued for almost 6 years. Mucoid diarrhoea appeared again several months before she came to our hospital. Serum total protein was 3-9 g/dL and albumin 2-4 g/dL. Serum IgG, IgA, and IgM levels were also decreased (174 mg/dL, 61 mg/dL, and 61 mg/dL). Scintigraphy using 99m technetium-labelled human albumin indicated protein loss from her descending colon. A considerable amount of immunoglobulins was detected in mucous discharge (IgG 102 mg/dL, IgA 69 mg/dL, and IgM 13 mg/dL). Colonoscopy showed sessile polyposis with a remarkable quantity of mucus attached to the surface, from the rectum to the distal descending colon with patchy normal intervening mucosa. Our first impression was of a protein-losing enteropathy with ulcerative colitis; however, the biopsy specimen showed no crypt atrophy and a hyperplastic epithelium with the surface. of the towards infolding epithelium, particularly filled with There was acute cells were mucus. Epithelial The muscularis inflammation mainly towards the surface. mucosae was disrupted and occasional smooth muscle fibres were present in the mucosa. She was diagnosed as having cap polyposis. As mucosal ischaemia has been suggested for the pathogenesis of cap polyposis,2 mucosal blood flow was
54-year-old
*Nobuhide
Oshitani, Yoshinori Moriyama, Takayuki Matsumoto, Kenzo Kobayashi, Atsuo Kitano *Third Department of Internal Medicine, Osaka City University Medical School, Osaka 545, Japan; Department of Internal Medicine, Jyuso Municipal Hospital, Osaka
2
3
Williams GT, Bussey HJR, Morson BC. Inflammatory ’cap’ polyps of the large intestine. Br J Surg 1985; 72 (suppl): S133. Campbell AP, Cobb CA, Chapman RWG, et al. Cap polyposis—an unusual cause of diarrhoea. Gut 1993; 34: 562-64. Géhénot M, Colombel J-F, Wolschies E, et al. Cap polyposis occurring in the postoperative course of pelvic surgery. Gut 1994; 35: 1670-72.
English
as
she is wrote
SiR-Francis Crick has written that "There is no form of more difficult to understand and more tedious to read than the average scientific paper"’ which bears out the argument in your Oct 21 editorial. Having edited three medical or scientific journals over the years, I support your lament about the poor state of written English in most of the medical (and scientific) press. There are several contributory factors, for some of which editors have only themselves to blame. I agree that when they meet, medical editors are much more likely to discuss subjects other than the clarity of the papers that they publish. There are a number of fashionable topics floating around and journalology seems certain to have its own journal before very much longer. The role of the statistician seems to have become overly influential, editors apparently considering that p values and t tests are more descriptive than words. I very much regret that editors are more likely these days to consult Bradford Hill than Fowler (although if they consulted Bradford Hill solely for matters of style, one would have no complaints at all). It is to the statisticians that we owe the awful device of the structured abstract which, as I understand it, was devised to satisfy the requirements of those who only read the abstracts of papers dredged up for them by their computer. We have even had the spectacle of an author decrying the use of "Whimsical titles" which "may leave the readers bewildered about the broad category under which the contents of a paper belong". Readers in this case refers to those who are attempting "partial text electronic coverage".2 If this is the kind of English to which browsing electronic data bases leads, the sooner they are banned, the better. The increased use of computers as a substitute for a trip to the library does nothing to encourage authors to try to express themselves well, but editors might improve the situation if they allowed authors to break free of the IMRAD (Introduction, Methods and Materials, Results, and Discussion) convention in which papers are presented. A more informal style of writing, with the use of the active voice rather than the passive, is likely to allow authors to present their work in a more readable and interesting way, and probably describe the train of events that lead up to the prose
Department of Respiratory Medicine, Northwick Park Hospital, Northwick Park and
A
We thank Dr D P Jewell for clinical advice and Dr B F Warren for histopathological review.
1
SIR-A patient presented with relapse of her psoriasis which had been in remission for a number of years. She attributed this to a change in her asthma medication from budesonide Turbohaler to fluticasone Accuhaler. The budesonide was reinstituted and the psoriasis cleared. Does this observation reflect a difference in the absorption pattern of the two drugs from the lung or does it infer the efficacy of inhaled budesonide as a treatment for psoriasis?
Protein-losing enteropathy from
measured with laser doppler. No difference was noted between the affected and non-affected mucosa. Cap polyposis affects both sexes over a wide age range (17-82 years).’ Aetiology is unknown, although mucosal prolapse and abnormal rectosigmoid motility’2 or infection3 may contribute to the pathological appearances. 1,2 Our patient had constipation for a long time before diarrhoea started. The muscularisation in the biopsy specimen indicated the presence of some degree of mucosal prolapse in this patient. It is suggested that persistent mechanical stimulation due to mucosal prolapse might lead to hyperplasia of the mucosa, leading to hypersecretion of serum proteins into the lumen surface.
1567
in a more realistic way than is possible otherwise. Authors should also be encouraged to use simple language and be as brief as possible; there is almost nothing said in ten pages which cannot better be said in five. And it is astonishing that so many people, who are able to describe their work in a clear, interesting way when talking about it, feel compelled to resort to the pompous verbosity that characterises so much scientific writing. There is much editors can do to raise the standard of written English in their journals. They will need to give much time and effort to it, commodities already in short supply, especially for most part-time editors; they will need to think less of their citation index and more of the duty that they have to their readers, which is to see that their journals not only instruct but also give some pleasure.
publication
H A Waldron, Editor, Annals of Occupational Hygiene, 31 Maidstone Road, London N11 2TR, UK 1
2
Crick F. The astonishing 1995. Kerr JR. Whimsical titles
hypothesis. are
London: Touchstone
deeply unhelpful. BMJ 1995;
Books, 311: 879.
SIR-The difficulties the scholar faces in the pursuit of elegance, the subject of your Oct 21 editorial, are not entirely self-inflicted. Serious journals accept little variation in structure or vocabulary and the papers they carry are highly conventional documents-one convention being that the author(s) assume that note of modest, depersonalised scientific humility which makes an individual voice hard to develop, and another that the structure of the paper should take the fun and suspense out of a good story. The 19th century saw the development of journals which put a premium on one version of stylistic excellence but at least there was space on offer to permit authors to unpackage their wares. Writers could offer a degree of idiosyncrasy. Moreover, a major genre of that era was the chronologically unfolding case study, a story in which the leading actor was the doctor himself-the man whose most basic feature of style was "I did this" and whose aim sometimes seemed to be to tell us how he felt, to share an understanding with readers of what it is to be a doctor. The sweep of the story from the introduction of the patient (with scant regard for confidentiality) as "Charles E May, aged 25, a sergeant in HM 51 regiment ... complained of having been feverish and unwell for some days ..."’ to his mysterious affliction to the denouement (often sadly, post mortem) is reminiscent of another chronologically ordered genre developed in that century, the detective story. Conan Doyle was a doctor; Sergeant May was an opium eater. Modern medical writing has the excitement knocked out of it: "Medical journals", as Asher remarked "are dull".2 For example, convention demands that the chaotic hit and miss of much real experimentation (the questionnaire the cat ate, the missing notes, the dropped test tube) be suppressed in favour of an account of seamless perfection.3 If they are mentioned at all, mistakes and oversights are squeezed into a couple of sentences. This draining of life from the scientific drama is part of the convention of authorial anonymity. In a medical journal today you must, unless you are very famous, present yourself as a humble faceless servant in pursuit of truth. This on occasion may mask a monstrous ego in pursuit of personal advancement, but it does not alter the convention. "I did this" as a means of advancing the logic of the paper is not permissible. We must recognise just how rigorous these conventions are and what a constraint on literary skill they impose. The organising principle of the contemporary medical paper no longer has the simple force of chronology, but undertakes a ritual dance through Introduction, Methods, Results, and
1568
Discussion. The constraints are not fully understood and are covered hardly at all by the International Committee of Medical Journal Editors. The example of "hedging", mentioned in your editorial, is typical. Hedging may indeed be badly deployed in academic papers, but this may simply be that the conventions are not well understood. For example, hedges in the discussion and the introduction will manifest in very different forms. A discussion section will be littered with "may", "perhaps" and the like. By contrast, hedging, as the authors’ way of distancing themselves from the truth value of the propositions they utter, will in the introduction be more commonly realised by the choice of reporting verbs to discuss the work of previous authors. "Smith showed [in her authoritative study]" is at one end of the scale and "Jones suggested [but we all know what a fool he is]" is at the other.’ Stylistic elegance presupposes the mastery of convention. A successful sonnet presupposes knowledge of the rhyme scheme and elegant medical writing presupposes knowledge of conventions no less closely adhered to but poorly described and hardly ever debated. Medical students receive little or no training in writing, and postgraduate "writing courses" are often taught by people with no understanding of linguistic structure or the conventions of the academic article. There are plenty of books for the would-be writer but the advice amounts to little more than vague exhortations to "be clear, be concise". ("Right", said the coach, "today’s tactic-score more goals than they do.") There is a desperate need for a better understanding of what is involved in good academic writing. Good writing and good thinking go hand in hand. John Skelton Department of General Practice, University of Birmingham, Birmingham B15 2TT, UK 1 2
3
4
5
Bowling JP. Abscess of the caecum, containing solid opium, in an opium-eater. BMJ 1853, Feb 18: 150-51. Asher R. Why are medical journals so dull? BMJ 1958; ii: 502-03. Gilbert GM, Mulkay M. Opening Pandora’s box: a sociological analysis of scientific discourse. Cambridge: Cambridge University Press, 1984. Skelton J. Analysis of the structure of original research papers: an aid to writing papers for publication. Br J Gen Pract 1994; 44: 455-59. Thompson G, Ye Yiyun. Evaluation in the reporting verbs used in academic papers. Applied Linguistics 1991; 12: 365-82.
SiR-In your excellent editorial you attacked the decline of the English language into ugliness and obscurity, and put much of the blame on scientists. We all know what you mean. A short time ago, a young British embryologist, working in California, submitted a paper to the university on "Pigment patterns in birds". The paper was accepted but the title was changed to "Pigment patterns in avians". "Why?" asked the author, "they mean exactly the same?" "Yes," replied the editor, "but ’avians’ is more scientific". This kind of pretentiousness and obscurity is not peculiar to scientists. A group of young lawyers, called "Clarity", is dedicated to improving legal language by simplifying it. The Council of Ministers of the European Community has ordered the Commission’s bureaucrats to use clear and simple language when drafting legislation, and told them how to do it. The daily Court Circular, will no longer, we understand, describe ambassadors to the Court of St James’s as being "extraordinary" and "plenipotentiary": they will be merely "ambassadors". Could doctors and scientists not deal with their own professions in the same way-the doctors led by The Lancet maybe? Hippocrates, they might like to remember, was admired for the conciseness of his style.
Eirlys Roberts European Research
into Consumer
Affairs, 8 Lloyd Square, London WC1X 9BA, UK