1820 BRITISH MEDICAL JOURNAL VOLUME 291 21-28 DECEMBER 1985

Medicine is war: and other medical metaphors

Br Med J (Clin Res Ed): first published as 10.1136/bmj.291.6511.1820 on 21 December 1985. Downloaded from http://www.bmj.com/ on 18 April 2019 by guest. Protected by copyright.
PAUL HODGKIN

When I worked in a paediatric casualty department children were A common variant of this is the "medicine is a detective story"
forever being told that after being stitched, x rayed, or covered in metaphor, in which the disease is the villain and making the
plaster they would be "bionic." The desire to be more machine like diagnosis approximates making the arrest:
is apparently widespread-inevitably perhaps, in an age when This sinister disease requires a rigorous history to be taken plus a
technology is both idolised and feared. Medicine is strewn with searc hing examination together with a high index of suspicion in order to
mechanistic language and concepts, and the metaphor "the body is a spot the tell tale clues and make the correct diagnosis.
machine" suffuses much of the language of pathology and physi- The Boy's Own Paper style is perhaps no accident since we talk,
ology. I write here about some of the linguistic forms that underlie think, and write about doctors within a tradition that sees them
the way we talk about medicine and the way that they limit as well as almost exclusively as men.
advance our thinking. The "medicine is war" metaphor also has more serious implica-
Examining the metaphors behind language is worth while tions as it emphasises that taking action is a virtue, patients are
because it clarifies our assumptions. Seeing the body as a machine, passive, the main protagonists in this drama are doctors and diseases
for example, has been useful-the heart, after all, is much like a (patients are not the "real" focus), technologies are weapons (and
pump and treating it as one has provided many insights. The success
thus, implicitly, the more the better), and we doctors know best as
of the mechanistic approach, however, has meant that we have often we are the ones in control. These attitudes clearly have some
imbued the body with other machine like attributes. All too easily advantages-for example, it is easier for doctors to bear the failures
patients become-like machines identical, passive and "fixable." of medicine if the "real" enemy is construed to be the disease. For
Medicine, as has often been pointed out, has become dominated by many specialties, however, including geriatrics, psychiatry, and
a mechanistic hubris, which sees machines and engineered solutions
general practice, using the "medicine is war" metaphor can be
to ill health as the favourite way forward.
counterproductive. In addition, the doctor's self image of battling
All this, of course, begs the question of the relation between the against disease may not be in the patient's best interest. The cost of
language we use and the things it describes. Some have felt that any our inappropriately aggressive attitude to fighting disease has often
language may actually prevent its native speakers from perceiving been borne by our patients as they have suffered, among other
the world in ways that are quite "normal" in other tongues.' things, tonsillectomy, hospital delivery, and the overprescription of
According to this view, language more or less deterrmines reality. A psychotropic drugs.
more orthodox position is that language and our perception of the
world evolve together, both influencing each other. The particular
vocabulary and syntax of any given language "do not make it
impossible to express certain things, they merely make it more Roles of doctors, patients, and disease
difficult to express them.'" The concept that patients are in part just the "clinical material"
The vocabulary of medicine is certainly one example of the way with which doctors fight the great battle against disease takes subtle
linguistic forms affect our perception of the world. As Dixon has forms. The word cohort, for example, was originally part of a
pointed out, we have 20 rubrics for different types of respiratory Roman battalion-a set of identical and ultimately expendable
infection but only one word for poverty.3 Differentiating respiratory soldiers to be used to the most useful advantage in winning the
syncytial virus from mycoplasma thus becomes possible, but we still battle.
have only general terms with which to express, say, overcrowding. Fighting wars is usually an unpleasant, boring, and masculine
Our language thus drives important factors to the margins of activity. The "medicine is war" metaphor perhaps encourages the
consciousness. virtues required to survive the long hours and intense hierarchies of
hospital life. Unfortunately, it also discriminates against feeling and
reflection and makes it harder to strike the right balance between
Most common themes work and personal life.
Another curious twist of medical language is the way that we
Much medical language is built around a few metaphors. Phrases habitually talk about diseases as if they were objects rather than
such as "He sank into a coma," "You're in tip top condition," and processes, saying, for example, "He's got mumps" and not "He's
"Falling ill" are constructed round the idea that health is up and mumping." Cassells pointed out how widely both patients and
illness is down. (This particular example is taken from an excellent doctors view disease as an "it," with an independent existence.5
book by Lakoff and Johnson,4 which describes in detail the Thinking of diseases as objects comes so naturally to us that it is
importance of metaphors in organising our thoughts and language.) difficult to see how this view is anything but helpful and necessary.
That health is up is hardly surprising. We are after all up and After all, this is the main way in which we have classified and studied
about when well and horizontal when dead or ill. A meatier medical illness. But to see disease as an object and not a process is to
metaphor is "medicine is war." The language that we use about our emphasise that one can indeed "get rid" of "it", that its arrival was
role as doctors is cast almost entirely by this metaphor and military probably unbidden and that cure is equivalent to physical removal.
images also appear in every aspect of medical language and jargon: As patients we can draw tight comfortable lines around the disease
It's an overwhelming infection; she's got an infiltrating carcinoma; the and say that the rest is normal. For doctors the disease, rather than
body's defences; he's having a heart attack; killer T cells; we must treat the context in which it occurs or its meaning for the patient,
him aggressively and use everything in therapeutic armamentarium; becomes the most important level of study. The corollary of the
we've wiped out smallpox; go to casualty and the house officer will deal "diseases are objects" metaphor is that patients are naturally seen as
with you; containers for those objects:
He's full of cancer; we've just got to get in there and control the bleeding;
I'm taking so many pills I'm beginning to rattle; we must get to the
Department of General Practice, University of Manchester bottom of the problem.
PAUL HODGKIN, MB, CHB, lecturer Again this is widespread and useful because in many ways we are
Correspondence to: 47 Collegiate Crescent, Sheffield S10 2BR. containers that we can physically put tablets into and take gall
bladders out of. To the extent that patients are seen as mere vessels
BRITISH MEDICAL JOURNAL VOLUME 291 21-28 DECEMBER 1985 1821

for disease, however, they will also be assumed to be passive and less overwhelming view of bodies as machines.6 These metaphors are

Br Med J (Clin Res Ed): first published as 10.1136/bmj.291.6511.1820 on 21 December 1985. Downloaded from http://www.bmj.com/ on 18 April 2019 by guest. Protected by copyright.
important than the disease itself. just as true as a mechanistic way of looking at physiology but would
emphasise, for example, the processes of keeping healthy and the
importance of nutrition. They assert our vitality and the shimmer-
Medicine and emotions ing complexity of living processes rather than the predictability of
the machine.
There is one last, intriguing aspect of language that is relevant to There are many other subjects that might yield additional new
medicine, which is the way in which we talk about emotions. Many metaphors and insights. We could, for example, reacquaint our-
of the phrases we use to talk about feelings depend on two selves with the word healing and all the many meanings that it has
assumptions: emotions are fluids and intensity is temperature. for both lay people and alternative practitioners. There is also a
He was swamped wlth feeling; she was bubbling over with joy; I nearly widespread lay metaphor "illness is imbalance." This is little used
exploded with rage; they were boiling over with excitement; they've by doctors but might form the basis on which some of the insights of
channelled their feelings into other things; he's emotionally volatile. modern medicine might be reconstructed for both patients and
The language of feeling implies an extensive network of sub- doctors. New scientific understandings are themselves a potent
terranean piping. The purpose of this subconscious plumbing is to source of new metaphors. The image of the hologram, which
prevent the unseemly spilling of emotions into the open, and indeed influences current research in neurophysiology, is an example of a
many of the phrases we use imply plumbing failures of one kind or new metaphor that emphasises the wholeness and interrelationship
another. If we do, heaven forbid, actually begin to feel something all of organisms.,
kinds of ills apparently lie in wait. The emotional fluids may even Finally, there is the fact that medicine has grown out of a science
vaporise under the heat of our feelings and end up clouding our governed and dominated by men and masculine patterns of
judgment. Within medicine, at least, emotions and feelings are thought.' Control of emotions and the pursuit of power are prized in
actually thought of as dangerous and contaminating fluids. this atmosphere. With the rising awareness that an excessively
The traditional way of dealing with this problem is by trying to masculine style of science has had considerable costs as well as
keep the emotional temperature as low as possible. Exactly how this benefits for humanity comes the possibility of other more complete
is to be achieved is rarely explained but it is certainly the method ways of proceeding. Perhaps we could learn a lot from a medicine
implicitly recommended in most teaching on medical and surgical less dominated by men.
wards. Apparently the mature doctor should be able to control the If we are to humanise medicine and create institutions that
emotional temperature of even the most tragic situations so that at encourage the full participation of patients, while offering them the
least his or her feelings remain nicely controllable as frigid blocks of best of traditional medicine, we need to incorporate new images into
ice. Such assumptions, of course, do little to help patients-or for our thinking. Essential to this process would be new metaphors
that matter doctors. around which we can reconstrue both our present and our emerging
The metaphors described in this article are pervasive and form knowledge. In the face of the further drive to reductionism that will
the basis of many of our concepts about medicine. They are often flow from bioengineering such unifying and believable metaphors
used among patients too, and form the normal, common sense way will be essential if we are to continue in any way to be healers as well
of thinking and talking about ill health and doctors. as technocrats.
Problems arise not because these ways of thinking are not
valid-at times all these metaphors are useful-but because their
pervasiveness excludes other equally true ways of seeing health and References
illness. The metaphors underlying our language create a subtle
pressure that is perhaps part of the reason that we find it so difficult I Whorf B. Language, thought and reality. New York: Wiley, 1956:207-19.
2 Brown R. In: Henle P, Arbour A, eds. Language, thought and culture. Michigan: University of
to think of people as wholes, as having a reality much greater than Michigan, 1972 :10-1 1.
the sum of their organs, diseases, or economic,value. Having such a 3 DLxon AS. Family medicine-at a loss for words.J7 R Coll Gen Pract 1983;33:358-63.
4 Lakoff G, Johnson M. Metaphors we live bv. Chicago: Chicago University Press, 1980.
restricted choice of language we are all too often forced, inadvert- 5Cassells EJ. Disease as an "it." Soc Scr Med 1976;10: 143-6.
ently, into useless, harmful, or insensitive ways of thinking. 6 Dossey L. Space, time & medictne. Boulder, Colorado: Shambhala Publications, 1982:73-4.
7 Pribham K. In: Wilber K, ed. The holographic paradigm and other paradoxes. Boulder, Colorado:
Shambhala Publications, 1982:27-34.
8 Easlea B. Science and sexual oppression. London: Weidenfeld and Nicolson, 1981.
Alternative metaphors
It is, of course, possible to try to create new metaphors with which
to weave a richer understanding of both illness and disease but this is
not easy. The old metaphors are hard to dislodge, while new ones Friday 13-a day to avoid?
inevitably seem precocious. From the witch doctors of the South Pacific to the faith healers of
Still, it is interesting to see what other metaphors might be contemporary society superstition and medicine seem to have been inextric-
available and the kinds of thinking they imply. An alternative to ably linked. For the most part beliefs in superstition are personal and
"medicine is war," for example, might be "medicine is a collabora- idiosyncratic, little affecting the everyday practice of medicine. In the past
tive exploration." This recognises that what we are engaged on is year, however, it has been noticed that the superstition that Friday 13 is a
exploratory-by its nature it is intrinsically uncertain. Although day connected with bad luck')2has led to many patients refusing to have
some people may have more expertise in particular aspects of operations performed on this day. We set out to see if there was any truth in
the superstition.
medicine than others, neither doctors nor patients have a direct line The total daily attendance at this hospital of patients sustaining injury on
to the truth. each Friday 13 between 1975 and 1985 was recorded, and the number of new
It also implies that medicine is cooperative and many people are attendances on the preceding Friday-that is, Friday 6-was also recorded.
involved: patients, their family, health workers, and researchers. The number of new accidents reported varied from 130 on 13 August 1976 to
Success depends on working together. Neither success nor failure is 280 on 6 October 1970. The mean attendance on Friday 13 was 196 (SD 39)
the sole responsibility of any one person; in other words, it is not the and on Friday 6 204 (20). There was no significant difference between the
surgeon alone who "cured" the patient but just as importantly the attendances by Student's t test. The results show that there is no evidence of
patient's own ability to heal himself together with the other an increased incidence of accidents on Friday 13. Although cynics may
members of staff, family, and so on. Embedded in the metaphor suggest that people are more circumspect on this day, and therefore less at
risk, the evidence is that Friday 13 is just another day.-J A FAIRCLOUGH, S R
too, is "labour," reminding us that medicine depends on hard work JOHNSON, D J SHEWRING, department of traumatic and orthopaedic surgery,
by both patient and doctor. Cardiff Royal Infirmary, Cardiff CF2 1 SZ.
Our bodies often replace almost all of their physical constituents.
Metaphors such as "the body is an enduring pattern" or "the body is 1 Leach M. Funk and Wagnall's standard dictionary offolklore, mythologv, and legend. London: New
English Library, 1975:425-6.
a biochemical dance" might profitably supplement the currently 2 Waring P. A dictionary ofomens and superstitions. London: Souvenir Press, 1978:97-8.