Metaphor and figures of speech
Medical writing deals mainly in facts, yet it often uses figures of speech, and much of its technical vocabulary began as metaphor. Figures of speech come in named kinds, and metaphor shapes thought as well as wording. An image or an analogy can make a concept clear to a reader, but a figure may not reach every reader in the sense the writer intended.
Figures of speech and their kinds
Literal comes from the Latin literalis, of or belonging to letters and writing, and came to mean according to the exact meaning of the word, such as its dictionary definition. Figurative refers to figures of speech, and a figure of speech is any deviation from literal meanings or common usage, whether a deviation from ordinary grammar or word order or the use of a word to mean something other than its customary meaning. Shakespeare often used figurative language to express intense emotion, and a paraphrase, a restatement of the meaning of a text or passage in different words, helps in understanding such a poetic passage. Stripped of its figurative language, Romeo's Juliet is the sun becomes I see Juliet through her window. She is more beautiful than her cousin Rosaline, who should be jealous of her, which captures the literal meaning but fails to express the intensity of his infatuation.
A metaphor is a figure of speech in which a word or phrase, such as the sun, is applied to an object or action to which it is not literally applicable, such as Juliet. The word metaphor comes from the Greek for to transfer. Having evolved from Greek words meaning between places and to carry, the word metaphor can itself be considered a metaphor. A metaphor transfers some attributes from a figure, also called a vehicle, to a ground, also called a tenor. In Juliet is the sun the sun is the figure and Juliet the ground, and Romeo's call on the sun to kill the moon contains three figures, sun, kill and moon, and three grounds, Juliet, displace and Rosaline.
A metaphor is an implied comparison, as when a wife's arrival at the bedside of a patient in the critical care unit is a ray of sunshine in his dull day. It is often made by using a linking verb to connect ground with figure, as in Juliet is the sun, or by referring to the figure in a way that suggests the ground, as the elephant in the room suggests an obvious problem. A simile is an explicit comparison of two unlike things, typically made with words such as as, like or than, as in A meal without wine is like a day without sunshine. Not all comparisons are similes: a simile takes the grammatical form of a literal comparison but expresses something that is not a statement of fact, as in Robert Burns's My love is like a red, red rose.
An extended metaphor sets up several subsidiary subjects or comparisons, as Romeo, once Juliet is the sun, can use the moon as a metaphor for some lesser woman. A mixed metaphor, sometimes playfully called a mixaphor, leaps from one identification to a second that is inconsistent with the first. In Merriam-Webster's example, If we want to get ahead, we'll have to iron out the remaining bottlenecks, an iron smooths out wrinkles, not bottlenecks. Mixed metaphors can be confusing, and they are sometimes used for comical effect. A writer who is not a professional comedian should avoid them. Metaphors and similes enrich writing, and the chief way a writer goes wrong with them is mixing the images, as in Following three days of gastroenteritis, the patient was bone-dry, like an old prune, or After a night on duty, the surgical resident was dog-tired, like a deflated inner tube.
Metaphors are often confused with metonyms. A metaphor creates a new link between two concepts from separate conceptual domains, as Juliet belongs to humanity and the sun to astronomy. A metonym relies on an existing conceptual link, as people in the United Kingdom, Canada and other Commonwealth realms often use the crown for the monarch, who occasionally wears one, or for the national government in general.
Some metaphors and other figures of speech are so overused that they become clichés, overused phrases or opinions that betray a lack of original thought, such as crystal clear and cool as a cucumber. Some clichés are metaphors, as in She dangled a carrot in front of his nose, and some are not, as the simile The explanation was as clear as mud.
Metaphors, similes and metonyms are not the only forms of figurative language. The Silva Rhetoricae website provides an extensive list of figures of speech, each named, defined and categorised. Many of these rhetorical figures have Greek or Latin names because they have been recognised since classical times as valuable in persuasion.
Metaphor in thought
Rhetorical devices considered poetic are equally available to medical writers. In Metaphors We Live By, Lakoff and Johnson hold that the generalisations governing poetic metaphorical expressions lie not in language but in thought, as general mappings across conceptual domains, and that most of our ordinary conceptual system is metaphorical in nature. They illustrate how everyday speech is understood in relation to an overarching metaphor, such as the mental construct that argument is war: claims are indefensible, weak points in an argument are attacked, criticisms are right on target, and arguments are demolished, won and shot down. Other metaphorical constructs arise from physical and cultural experience. People intuitively associate emotional states with physical space, happy with up and sad with down, as in feeling up, boosted spirits, being in high spirits, feeling down, being low and spirits sinking.
Writers who eschew metaphor in an attempt to make their prose completely transparent labour under a false assumption rooted in a positivist perspective, that the world consists of objects independent of any people who experience them. The positivist movement held that all meaningful statements are either analytic or conclusively verifiable, confirmed only through observation and experience. The standard dictionary-maker's view of definition assumes that experiences and objects have inherent properties and that people understand them solely in terms of these properties. Lakoff and Johnson describe four fallacies stemming from a positivist conception of language and reality: that metaphor is a matter of words, not concepts; that metaphor is based on similarity; that all concepts are literal and none can be metaphorical; and that rational thought is in no way shaped by the nature of our brains and bodies. They reject the view that metaphors are nothing but linguistic expressions, a mere matter of words, and show how sophisticated concepts are made clear by deeply structured, interacting metaphorical thought processes.
Scientists use metaphor and analogy to make sense of the world and to express their ideas to others, so they often use metaphors in their writing. Literary invention can clarify abstract scientific concepts, and some scientists find personification apt for physical phenomena. One molecular biologist, when trying to think through a chemical problem, would ask himself what he would do if he were an electron. Peter Atkins pictures a light beam passing into a medium of higher refractive index, which slows it down, as a lifeguard racing to rescue a drowning swimmer. Because the lifeguard can run faster than he can swim, he should not head straight for the swimmer, and running to the point on the beach directly opposite is better but still not the best: he should take the optimum intermediate angle, which yields the ideal combination of fast running followed by inevitably slower swimming. In Richard Dawkins's view, original use of language can yield greater insight than a more prosaic approach, and novelty of language and metaphor pushed far enough can end in a new way of seeing.
One practitioner challenges the idea that literary devices such as metaphors do not belong in medical writing, holding that metaphors can help medical writers describe and explain science and persuade people about the scientific argument.
Metaphors in medical vocabulary
By adopting the names of familiar objects for anatomical parts, medical language was originally highly metaphorical: bursa, Medieval Latin for purse, came to signify the pouch lined with synovial fluid near a joint.
Metaphors and similes are often used in medical writing, and some are embedded in medical terminology, such as coffee-ground vomitus, cotton-wool exudates, leonine facies and spider nevi. Metaphors, analogies and similes have a long tradition in medical writing in particular and can evoke graphic images with ease, as strawberry tongue, nutmeg liver and cauliflower ear do. A penetrating injury is said to have invaded the abdominal cavity, poorly perfused feet are cold as ice and the skin of an anaemic patient appears pale as a sheet.
Interventional cardiology describes some of the techniques and concepts of percutaneous coronary intervention (PCI) with metaphors, such as buddy wires, kissing stents, monorails and mother-and-child. A buddy wire technique uses an additional guide wire along with the one routinely used, to advance balloons, stents or other devices and help accomplish otherwise challenging procedures during PCI. A kissing or snugging technique deploys two or more balloons or stents in arterial bifurcations, where the devices eventually meet in the vasculature and kiss or snug. A mother-and-child configuration inserts a small catheter, the child, into a larger conventional guiding catheter, the mother, during PCI. The monorail balloon shaft and guide wire is a concept named after the monorail train system of the 1980s, with the balloon catheter running over the guide wire. The pillows and grooves of a balloon are its segments that make contact with the blood vessel walls and function to minimise local forces, interspersed by grooves. The metaphors get more interesting as the interventions become more complicated, as in the double-kissing crush approach or the 4-in-5 mother-child technique.
Many scientific terms started as metaphors. Robert Hooke used cell, which literally meant a small room, for the microscopic structural units he saw in plant tissue, and the word came to be the official name for the smallest structural and functional units of all living things.
A dead metaphor is one that has lost its metaphoric force through common usage and is no longer a figure of speech, and the expression is itself metaphorical, because a metaphor is never literally alive. Many technical terms started as metaphor only to become standard terminology: once the biologists' definition of cell was added to the dictionary, using it for the smallest structural and functional unit of an organism stopped being a figure of speech. A metaphor is merely dead if the term's new meaning has become widely accepted, and really most sincerely dead if its original meaning has been forgotten. A mainstay was originally the rope or wire that held a ship's mainmast in position, and few people now know the terms for nautical rigging, yet they commonly use mainstay for something on which someone or something depends. A large proportion of the technical vocabulary of medical writing consists of dead metaphors, such as cell, and of metaphors that are not quite dead yet.
Images that clarify a concept
Metaphors, analogies and similes can facilitate comprehension of complex subjects by providing familiar points of reference to readers. Used judiciously, such aids can enhance both the relatability and the readability of scientific documents. The writer's struggle is to create metaphors and similes that are novel, and perhaps even memorable, as when Flannery O'Connor, in A Good Man is Hard to Find, depicts the face of the mother as broad and innocent as a cabbage.
Words can be used to create vivid images in the mind. That tobacco causes the deaths of 400,000 Americans each year is a big number. That more than 1000 people in the United States die each day of the effects of tobacco use has a little more punch. The word picture that the loss of life in the United States due to tobacco use is the equivalent of three jumbo jets crashing each day has, for one writer, dramatic impact. A metaphor is often a way of taking an abstract idea, such as someone being annoying, and putting it in a concrete form. A listener who hears that someone is skating on thin ice knows that no one is actually skating, but that the person might be annoying someone or be about to be reprimanded or confronted.
An analogy from the humanities can carry a scientific concept, as in one comparison of basic concepts of immunology and vaccines with magical concepts from J. K. Rowling's Harry Potter and the Prisoner of Azkaban. The comparison draws on that novel because one of its major themes is how young wizards and witches learn to defend themselves against harmful magic. In 2007 the choice was also timely, since premedical, medical and science students would probably know the Harry Potter series by heart within the next 5 or 10 years, and the novel had appeared as a film for audiences worldwide. In the novel, Professor Lupin's best teaching tool is the boggart, a shape-shifting ghost that takes the form of whatever an individual fears most. He teaches the students a simple spell that neutralises it by changing it from something frightening into something harmless or laughable, such as a roaring lion into a purring domestic kitten. Just as the boggart trains the young witches' and wizards' minds to prepare for and react to harmful spells and creatures, a vaccine trains the body's immune system to handle dangerous pathogens. The most important philosophical similarity between them is that both give people a way to recognise something fearsome or threatening and to mobilise their own resources to conquer the miniature form of the threat, so that the full form of the threat or pathogen does not come as a surprise.
With the Patronus charm, Harry learns to create first an indefinite silvery cloud and much later a silvery cloud in the shape of a stag. As the cloud, the stag and the memory of empowerment work together to drive away the creatures that threaten him, humoral and cellular immunity work together to defeat the pathogens that attack the body. The silvery cloud is the equivalent of nonspecific interferons or B-lymphocyte-produced antibodies, and the stag the equivalent of T lymphocytes or macrophages, which directly kill the pathogen. A person exposed to the pathogen through the vaccine, as through the boggart, has an immune memory of it and can call on the memory of defeating the miniature pathogen to neutralise the full one. A teaching approach that combines scientific information with philosophical, literary and historical concepts does much more than merely provide compelling ways to remember scientific information. In the light of other subjects and points of view, instructors and future physicians can look at their own work and see the framework and structure that hold together what they are doing, and only by knowing that framework and structure can they sort out the welter of details involving test results, cell counts, anguished patients and ever-more-difficult choices.
To help lay readers understand scientific and medical concepts, reporters who have pulled the reader in with three-dimensional characters and scenes might use metaphors. In The Immortal Life of Henrietta Lacks, Rebecca Skloot writes that under the microscope a cell looks a lot like a fried egg, with a white, the cytoplasm, full of water and proteins to keep it fed, and a yolk, the nucleus, that holds all the genetic information that makes you you. The cytoplasm buzzes like a New York City street, crammed full of molecules and vessels shuttling enzymes and sugars and pumping water, nutrients and oxygen in and out of the cell, while little cytoplasmic factories work around the clock. The nucleus is the brains of the operation, holding in every cell an identical copy of the entire genome, which tells cells when to grow and divide and makes sure they do their jobs. The image puts all readers at ease: falling early in the book, it makes readers feel that perhaps the subject matter isn't too complicated for them, and they press on to the next page.
A cell biologist might not be completely comfortable with so non-scientific a description of a cell, but by design it makes readers quite comfortable. Leaping right into the roles of the nucleus and the cytoplasm would have lost some insecure readers, whereas the fried egg gives readers an image they can call up quickly in their mind. Zooming in on the cell then makes the image more complicated, but no more so than a busy New York City street, which is as easy to conjure up as the fried egg. As one journalism teacher puts it, a good health story makes readers feel smart, and at the end of the passage readers can congratulate themselves that the author explained the inner workings of a cell and they got it.
When figurative language suits medical writing
Medical writing deals mainly with facts, so most of what is written should be literally true, but it is sometimes acceptable and even necessary to use figurative language, such as metaphors and metonyms, that does not express literal truth. There are no unbreakable rules for using figurative language in medical writing. Medical writers are mainly concerned with conveying facts and truth rather than expressing emotion artistically, so they should be cautious about using figurative language, especially when their audience includes poor readers or non-native speakers of the writer's language or the text is going to be translated.
One good reason to use figurative language is to help readers understand a complicated system or relationship by drawing an analogy to something they already understand or that the writer can at least explain. Many of the terms for how cells communicate with each other, such as signal, amplification, gain and feedback, came originally from radio and lost their metaphorical force through common usage among cell biologists. Another reason is convenience. Evolutionary biologists often talk about the evolutionary strategies of bacteria, plants and lower animals, and this use of strategy is a metaphor, because the strategies are nothing an organism consciously chooses to do. The phrase is a dead metaphor, since the dictionary already gives strategy the sense of an adaptation or set of adaptations that contribute to evolutionary success, so among microbiologists the word is a shorthand for that concept. Shorthand is itself a dead metaphor, from a method of rapid writing using abbreviations and symbols to a short and simple way of expressing or referring to something. Some members of a lay audience may not understand that an evolutionary strategy is not something the organisms are planning to do, so depending on the intended audience a writer may have to avoid a shorthand or at least explain what it means.
Metonyms can also be used in medical writing, albeit cautiously. The practice is often used as a metonym for a business in which one or more medical practitioners provide care to patients. It suits referring to that business as a business or without specifying a particular part of it, so if patients can contact any member of staff, a writer can urge them to contact the practice. The goal should be clarity.
In general, a writer may wish to avoid unnecessary figurative language in a technical report, such as a clinical study protocol, especially one that is going to be translated. There is considerably more room for literary inventiveness in an opinion piece, where authors may wish to express their own emotions and evoke emotions in the audience, especially to underscore the importance and urgency of their message, and may use figurative language for rhetorical effect.
How readers take a metaphor
Metaphors and analogies can be used by writers to explain complex concepts, but the interpretation is open to the culture of the reader, so a metaphor may be easily misunderstood. Metaphors are tricky because they are often contextually and linguistically bound, and a metaphor that works in the United States might not work in another part of the country, or particularly in another country. Low-skilled readers often interpret words literally, thereby missing the meaning. Some privacy notices state that the health record serves as a tool to help the health care professionals, but in many readers' minds tools are hammers, saws and drills, and they wonder how pieces of paper can be a tool.
By 2013, seven years after it appeared, Thomas Friedman's bestseller had become an icon and flat world a favourite buzzword in commerce and technology, and one medical writer asked whether medical writers would know the metaphor and how widespread the phrase was in other fields, such as medicine. Seven medical journal titles published between 2008 and 2012 use the figure, on cardiology, tropical diseases, cross-border reproductive care, medical education, medical outsourcing and telemedicine, and surgery. To that writer, they suggest that the global playing field in medicine has also been flattened, and they leave open whether it has in medical writing.
A manuscript that analysed long-forgotten medical research projects that are suddenly rediscovered, likening them to sleeping beauties awakened by a prince, was rejected by a top US journal on the grounds of sexualisation by using a politically incorrect analogy, and hibernators and awakeners were suggested as alternative terms.