Dialect Is Diagnostic
JOHN F. BURNUM, M.D.; Tuscaloosa, Alabama
Folk medical language, as spoken in western Alabama,
contains medical dialect terms that have an ancient
lineage, with structure and meaning very similar to those
of their earliest roots. The dialect has precise medical
meanings and is used with astonishing accuracy by
patients. Terms and phrases are often diagnostic as well
as colorfully descriptive. An appreciation of medical
dialect makes practice more fun, history taking and
diagnosis easier, and lessens misunderstandings with
patients. It sharpens the physician's senses to every level
of what patients feel and say, verbal and otherwise. An
appreciation of dialect heightens respect for patients and
gives the physician a sense of continuity with cultures and
ages past. Understanding and respect for medical dialect
can be a powerful aid to patient care.
M E D I C A L CARE begins with taking the patient's history,
with communication. Patients often express themselves
in unscientific folk talk that I had always considered
quaint and picturesque, but of little practical value in
medical dialogue. I was wrong. In my study of the folk
medical language spoken by patients in western Alabama, I found that medical dialect words and phrases
have ancient origins and precise medical meanings that
are close to those of their etymons. They are colorful and
expressive and are used with astonishing accuracy by patients. The phrases and words are alone often diagnostic
of the patient's condition.
Origin and Meaning of the Dialect
My respect for medical dialect began when I saw a
patient said to be having a drawing spell, which was hyperventilation. A standard meaning of draw is to inhale
(1). Patients with hyperventilation have trouble breathing in; they cannot draw in a satisfying deep breath. The
condition is not simply a matter of excessive breathing, as
the word hyperventilation indicates. A drawing spell,
therefore, is a more accurate term than hyperventilation
and is virtually specific in western Alabama of this diagnosis; patients with shortness of breath from heart or
lung failure do not complain of drawing spells.
Soon after, I saw a patient with a blotchy, purplish
discoloration of the skin from circulatory insufficiency
who was said to be purple pieted. Pieted or pieded derives
from pie or magpie (a mottley, splotchy colored bird),
and originally from pika (the Sanskrit word for the Indian cuckoo) ( 1 ) . Imagine, Sanskrit being spoken in rural
Alabama. I have been a devotee of patient language ever
since.
The etymology of the medical words spoken by patients explains the words' uncanny accuracy and appropriateness. My feet are strutted means they are tight and
swollen. Strut, Old English strutian ( 2 ) , has an origin in
common with cholesterol. Stereos is the Greek term for
hard or solid ( 2 ) . Cholesterol was first found in gallstones: thus, chole-stereos, the hard solid substance in
bile. In a similar fashion, but with an unrelated word,
patients may say that their arms are corded, a stiff,
bound, tight sensation. A patient who had hypokalemic
paralysis was said to gape for breath. The patient had
fish-mouth agonal breathing; gape, Old Norse gapa,
means to open the mouth wide. The gapes in the 19th
century novels of Jane Austen meant a fit of yawning
(2). My knee is quickie means that the knee is sensitive
and has sudden sharp pains. Quick, Old English cwic,
means alive or living and is a good Teutonic Elizabethan
word: the "quick and the dead" in the Apostle's Creed,
and in Hamlet (end of Act II) "tent him to the quick."
Quick with child is to be pregnant, and the quick is the
sensitive flesh under our nails (3, 4 ) .
Grandpa is stubborn means that he is constipated,
Stubborn derives from stub, the stump of a tree, that
unyielding part that is fixed in the ground ( 1 , 5). What
could be more expressive? (The origin of stubborn is unclear to some etymologists [ 4 ] ) .
Patients with those old leg rickets have restless shaky
legs. Richitis means an inflammation of the spine, rickets
(2), that causes the patient to be rickety, unstable, and
shaky. Sprangle is a beautiful word: The pain sprangled
out, spread out over the chest. The word means to branch
out ( 6 ) , as in a plant. In old Scottish and American dialect, it means to spring to get free: The sheep sprangled
away ( 3 ) .
To persh (perish) to death means the patient is starving and wasting away and derives simply and exactly
from the Latin perire, to come to nothing ( 1 ) . Null, from
null us, not any, is another good Alabama Latin word,
meaning to sooth or diminish ( 1 ) : The pain nulled down,
or Give me some nulling medicine. Plum is yet another
Latin word used in the United States since at least 1787: /
am plum give out, completely and utterly exhausted. It
comes from plumb, lead, and plumb bob, the lead weight
on the end of a line used to find the true vertical ( 6 ) .
/ took with an agures chill is, of course, a redundancy
and a variation of ague, a standard word for chill and
fever ( 6 ) . An agures chill in Alabama, however, is a particularly violent chill and alerts the physician to the possibility of serious sepsis. A nervous rigor may be confused
with a chill but is characterized by the patient alternately
tensing and relaxing the muscles over the body, shivering, and the absence of fever; it is a type of anxiety attack.
Ramshack (my blood pressure runs up and ramshacks
my nerves and my brain) comes from ramshackle and
ransack, from the Old Norse rannsaka, to pillage or
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©1984 American College of Medicine
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throw into disarray ( 1 ) .
I ate a bait of peas means just what it says, I ate a
portion of food, and is almost literal Anglo-Saxon (bat,
food) ( 1 ) . Bate (the pain bates down), on the other
hand, is short for abates. Hark (he harked up phlegm),
means to cough or clear the throat and is, I believe, a
variation of hawk, which means the same and is imitative
of the sound of this act ( 3 ) . Being salivated now means
to be devastated by an illness, but in the last century it
referred to the copious flow of saliva caused by mercury
poisoning ( 1 ) , often due to overzealous purging with calomel. Peart and pyert are variations of pert, lively, in
good health (3): She feels right peart today.
A pone is a lump or swelling and is the Algonquian
Indian word for a loaf of cornbread ( 1 ) . Patients from
the South are frequently concerned about pones. In my
experience pones are usually harmless accumulations of
fat, particularly in women, behind the knees or in the
axillae. Alabamians have not forgotten their Chaucer:
Hope me means help me, just as Chaucer's holpen meant
to help or heal ( 7 ) . Neither have they forgotten their
Shakespeare: Loss of courage still means loss of sexual
desire or potency ( 1 ) .
Both smart (6) and sight ( 1 ) , largely Southern dialect,
indicate a considerable amount or good deal: / drank a
right smart of beer, or I have a sight of gas on my stomach. Both want to (2) and bad to, more Southern talk,
mean an inclination or tendency towards: / want to be
dizzy when I stand; I am bad to eat sweets. Sull means to
sulk or balk: If I cross him he will sull up on me. Sull was
originally applied to animals and has been used for the
last 100 years in the Midwest and South (6); opossums
sull when they play dead.
Miscommunications
Words may mean one thing to the patient but something else to the physician, leading to dangerous misunderstandings on both sides. When patients say they are
deathly sick, they mean they are nauseated. Ill means
irritable or out of sorts, not sick as we think of it. Hypertension to the patient is not high blood pressure, but being tense and high strung. Unless physicians make it clear
that we are referring to elevated blood pressure, the patient may fail to return for critical follow-up care. On the
other hand, the diagnosis of tension headache by the physician is mistakenly equated with high blood pressure by
the patient. Low blood is a common folk diagnosis for a
vague admixture of low blood pressure, anemia, and lack
of energy. Whatever the cause, low blood is highly resistant to treatment and is often associated with the blind
staggers, dizziness or light headedness. The diagnosis of
gastritis (gas-stritis) is especially satisfying to patients,
because it confirms their own opinion that they suffer
from gas.
Misspellings and Misusages
Some words have become misspelled and mispronounced. Having prostrate trouble is certainly more descriptive than having prostate trouble. Highly seasonal
foods upset me. Hiatus hernia has become hiatrus; hys900
terectomy, hysterectum; vagina, regina; grimace, grimmich; vomit, vomic; glucose, gluco water; oxygen, octagen; curious, curous; queer, quare; enema, nema; pus,
pulse; and retch, reach. Throbs and tolerable have lost
their r's and become thobs and tolable. The letter r is
dropped frequently in Southern speech. It is fun to know
that groggery, groggy, dazed and unsteady, comes from
Old Grog; the name given to Admiral Edward Vernon,
an English naval officer who served rum to his crew and
who wore a grogram coat, a material of that day ( 1 ) .
There may be grammatical errors. Nauseous has replaced nauseated nationwide: / am nauseous.
Colorful Expressions
The medical vernacular is often vivid and expressive.
The phrase There won't nothing lay on his stomach is
more descriptive than is intractable vomiting. I haven't
seen anything yet suggests fear of pregnancy as well as
delayed menstruation. My eyes glimmer and feel bleary is
as good as scintillating scotoma of migraine. Patients
with dyspnea hassle like a dog, and those with emphysema hunker down to breathe, squat down and bend forward to better empty the lungs. This rash terrifies me to
death means that the itching is tormenting; the same idiom was used in Northamptonshire, England, in the mid19th century ( 3 ) . Trouble down there is a delicate reference to the genital area. My head rose signifies a purulent
middle-ear infection, and shortness at the breast is another term for dyspnea.
Patients with modern plumbing continue to say I have
to go outside too much or / have to be excused too much
instead of complaining of diarrhea, and for the same
complaint, they say My stomach is torn up. Patients ask
for something to regulate the bowels, never for medication for constipation. Our patients still hold the medieval
belief that constipation is due to a malfunction of the
liver, imbalance of humors, or lack of bile production,
and thus complain when constipated of having a torpid
liver or that the liver is not kicking off just right or that
they need something to touch the liver.
Diagnostic Terms
Just as chest pain described as the feeling of an elephant sitting on one's chest strongly suggests myocardial
infarction, colloquial expressions used by patients often
have high diagnostic specificity. In addition to drawing
spells, the diagnosis of hyperventilation and nervous tension (which merge into agoraphobia in some patients) is
almost certain when the patient says The air won't go
down deep enough or The breath doesn 't do me any good
or doesn't satisfy me. That shot didn't do me any good
suggests drug dependency; the patient is explicitly telling
us that he wants something to make him feel good, not
merely to relieve pain.
Depression is a common diagnosis often missed in office practice. Twenty percent of my female patients and
five percent of the men are depressed, but they rarely, if
ever, complain of depression. Their opening complaint,
however, is often diagnostic: / can't make myself go; I
wake up in a dread; Seems like nothing don't satisfy me
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no more. Being familiar with these expressions allows the
diagnosis to be made quickly and at considerably less cost
than that for the Cortisol suppression test (which has
only 50% sensitivity) ( 8 ) .
Discussion
Medical dialect spoken by patients in Alabama is,
broadly speaking, English in origin. Although most of
the words are classified in dictionaries as being archaic or
obsolete, they are in fairly common use in rural areas and
among less sophisticated people. Medical dialect should
not be demeaned by being grouped with slang, psychobabble, or the grotesque neologisms and jargon of the soft
sciences ( 9 ) . On the contrary, dialect expressions have an
ancient lineage, have been spoken by entire cultures for
generations, and have meanings that are very similar to
those of their earliest roots. The dialects are, for the most
part, used with exquisite appropriateness by patients and,
if we but understand, mean exactly what they say. Once
again, if we listen closely, the patient will tell us what is
wrong.
Studying folk medical talk has added zest to my daily
practice, made history taking and diagnosis easier, and
lessened misunderstandings with patients. In addition to
becoming familiar with the literal meaning of patients'
words, I have become more sensitive to every level of
what patients are feeling and saying, verbal and otherwise. Understanding and appreciation of medical dialect
has increased my respect for patients and given me a
satisfying sense of continuity with cultures and centuries
past.
Like most human endeavors, medical care turns on
communication, but communication may flounder because the patient and physician speak different medical
tongues. It is the physician's responsibility, however, to
understand the patient's language, not he ours. Medical
dialects differ from region to region and subculture to
subculture. Some physicians will have to be familiar with
several different dialects; the task is compounded for foreign medical graduates (10, 11). But learn we must. We
do not and cannot care for the patient we do not understand.
• Requests for reprints should be addressed to John F. Burnum, M.D.; 400C
Tenth Street East; Tuscaloosa, AL 35401.
References
1. Webster's New International Dictionary of the English Language. 2nd
ed. Springfield, Massachusetts: G. & C. Merriam Company; 1945.
2. MORRIS W, ed. The American Heritage Dictionary of the English Language. Boston: Houghton Mifflin Company; 1969.
3. W R I G H T J. The English Dialect Dictionary. London: Henry Frowde;
1905.
4. The Compact Edition of the Oxford English Dictionary. Oxford: Oxford
University Press; 1971.
5. K L E I N E. A Comprehensive Etymological Dictionary of the English
Language. Amsterdam: Elsevier Publishing Company; 1966.
6. C R A I G I E WA, H U L B E R T JR, eds. A Dictionary
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8.
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11.
of American
English on
Historical Principles. Chicago: The University of Chicago Press; 1938.
SKEAT WW, ed. The Complete Works of Geoffrey Chaucer. London:
Oxford University Press; 1931.
BURNUM J F . Diagnosis of depression in a general medical practice:
observations on "lack of pizzazz," the "blahs," and other complaints.
Postgrad Med. 1982;72:71-3, 76.
SCRUTON R. Review of The State of the Language. Lond Times Literary
Suppl. 22 Feb 1980.
M I L L W A R D CM. Familiar English for foreign doctors. N Engl J Med.
1970;283:430-1.
KIMBALL CP. Medicine and dialects [Editorial]. Ann Intern Med.
1971;74:137-9.
Burnum
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