Neville Goodman’s metaphor watch: I’m in the army now

neville_goodmanMany metaphors are helpful; many metaphors are irritating; a few are harmful. It’s not surprising that military metaphors abound in medical writing: disease is the enemy; drugs are the weapons with which to fight. Then we can write about, “The armed truce between the intestinal microflora and host mucosal immunity,” or about how our victory over tuberculosis is more realistically a truce, or about a truce between factions arguing that crystalloids are better than colloids. In truth, the last of these is a literal truce, in that it is an agreement between people to stop arguing; the intestinal microflora and M. tuberculosis have no thoughts in the matter.

It is easy to lapse into military metaphor. However appealing to journalists, writing of patients’ battling cancer or of being brave to do so is thoughtless. Describing the general drive to improve cancer treatments as a battle is less personal but still inappropriate. It’s not just cancer: there are battles against infectious diseases, battles in the treatment of stroke, the battle against human trafficking—although that really is a battle. In which people die. Extending the metaphor livens it up (for a while): battle of the bulge applied to obesity or to aortic aneurysms. But what we’re really writing about with our battles, our fights and our wars, are efforts, arguments, problems and difficulties: less sensational, more truthful, and better description.

Some military metaphors work. In auto-immune diseases, antibodies don’t really attack body cells, but destroy isn’t correct because it is the antibodies’ binding to receptors, thus initiating a response, that does the damage. Please don’t ask me for any more detail. My medical student career ended before immunology really began: my immunological knowledge is something shaped vaguely like a capital Y and “Fab,” and I’ve just had to look up what that stands for.

Bailey and Love (pale, bulky and offensive) strikingly described cancer of the stomach as “one of the captains of the men of death.” Its 26th edition is blue, and I don’t know if the metaphor is still in its pages, but it didn’t originate there. In 1918, William Osler referred to the Pneumococcus as the “captain of the men of death,” citing John Bunyan as its originator (The life and death of Mr Badman, 1680). Bunyan meant consumption, itself a metaphorical name for tuberculosis. No: thinking about it, consumption is a literal name, because that is what happened, just as diabetes mellitus is “sweet urine.”

Time bombs, often ticking, are used to warn us of the same apocalyptic horsemen—a biblical metaphor—that cause rising tides (q.v.): obesity, diabetes, Alzheimer’s, hypertension, antibiotic resistance. Efforts to defuse the bombs start with launching campaigns. But in all this metaphorical blether it is easy to forget—while the doctor is busy slaying the disease—that the battleground is the patient. While one of the combatants might emerge victorious and more or less unscathed, the battleground rarely fares well. I am far from the first to ask for special thought before lobbing another shell over the trenches in pursuit of a disease-free world.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that my only competing interest is my co-authorship of a book about medical English.

Neville Goodman is a retired consultant anaesthetist and a writer, and co-author of a book on medical English.

  • Could not agree more, Dr. Goodman. The battleground IS the patient. Thank you for this!

    Dr. Jack Coulehan (editor of the 5th edition of ‘The Medical Interview’ textbook) once wrote that the three most prominent metaphors used in medicine are:
    1. Paternalistic (parental)
    2. Engineering
    3. War

    He believes that paternalistic metaphors have faded in popularity, but war/combat comparisons are still distressingly common. To me, the most cringe-worthy aspect of this usage is the implication that those who “lose the battle” against their diagnoses somehow just haven’t fought as bravely as those who “win” that battle.

    And that is both hurtful and thoughtless. More on this in “She’s A Fighter!” http://myheartsisters.org/2013/02/12/metaphors-in-medicine/