Nouns, adjectives and prepositions do not change their endings in English to indicate how they relate to each other. Words can be stressed in speech, but although underlining and italics will indicate stress in writing they are devices to use sparingly. Some journals will not accept italicized emphases. In written English, meaning is determined first by the positions, or presumed positions, of words, phrases and clauses, and second by the punctuation between them. (Chapter 17 contains a more general consideration of word order, aimed at EAL writers.)

Consider this simple example.

Readers expect near to qualify the word next to it, clinical. Although it takes only a moment to realize that the sense is of a clinical near-disaster and not of a disaster that was nearly clinical, the expression is a jolt to the flow of understanding. The example is better as The policy was changed after there was nearly a clinical disaster.

Sometimes the interpreted meaning may be far from the intended one, as in this letter from a firm of solicitors to a general practice:

Note the lazy slash, which is better replaced with and.

The word only needs careful placement.

Noun clusters and stacked modifiers

In our opinion, to realize the problems produced by strings of unfamiliar modifiers is the simplest single way to improve medical writing. (And not just medical writing: did The Guardian newspaper really mean to describe a member of a pop group as a ‘fake tan-loving singer’?) There have been many examples in the preceding chapters.

Judicious punctuation of the strings helps the editor and readers to sort out what is meant, but often the difficulty of placing sensible punctuation shows that all is not well. Somehow we doubt if this example from an advert in the medical press could have been made less dubious or offensive by punctuation: ‘Wanted: brown fat research assistant.’ (And see the problems for Swedish writers, p. 250.)