Thinking with Metaphors in Medicine: The State of the Art by

Alan Bleakley (review)

Anita Wohlmann

Literature and Medicine, Volume 39, Number 1, Spring 2021, pp. 163-168
(Review)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/lm.2021.0012

For additional information about this article

https://muse.jhu.edu/article/796714

[ Access provided at 12 Feb 2022 14:25 GMT with no institutional affiliation ]

Book Reviews 163

that will follow. The professionalization of literary criticism, a story

told in part by Moi, was necessary in its time. In historical cycles,
however, what begins by liberating something ends up suppressing
something else.
The metaphor of the Protestant Reformation took over my think-
ing as I held these books together. What they offer is nothing less
than a new dispensation of readership that has no need for priestly
mediation. What counts is that literature connect to the life of the
reader; more exactly, the moment when a reader feels that connection,
moments that seem, as Davis describes them, to be a form of secular
grace. The connections of reading to life should remain multiple and
unstable, never settling into another fixed narrative that sets boundaries
around a life’s possibilities. What counts is how companionship, both
with what is read and within communities of shared reading, enables
confronting fears, being able to see through them to what Georgina,
with whom I started, calls “what’s really going on.” Although if you
asked her what that is, she would probably reread to you, aloud, a
passage from Conrad; that’s the circularity of it.
This new dispensation for reading does not put critics or teachers
of literature out into the cold. Davis’s research and The Reader’s practices
both emphasize that reading needs dialogue with other readers, and
dialogue needs facilitation—but facilitation is not mediation. Davis’s
continuing work as a literary biographer shows how scholarship still
has a vital role. But these books mark a shift in locus of authority
and in purpose. Reading is for life.

Alan Bleakley. Thinking with Metaphors in Medicine: The State of

the Art. London: Routledge, 2017. 270 pp. Hardcover, $160.

An emeritus Professor of Medical Humanities, Alan Bleakley has

written what he calls “the first comprehensive and systematic account
of metaphors in medicine” (203). Though he also refers to works of
classical literature, including those by Ovid and Shakespeare, Bleakley
focuses nearly exclusively on the use of metaphor in the practice of
medicine, drawing from specialties such as pathology, radiology, der-
matology, and psychiatry. In analyzing the ways doctors and patients
use metaphors for meaning-making, diagnostic purposes, and com-
munication, Bleakley is also concerned with their abuse and overuse.
164 LITERATURE AND MEDICINE

Thinking with Metaphors in Medicine is not driven by an over-

arching thesis about metaphors. Still, there are several interlinked
arguments throughout the book, such as the notion that “medicine is
a flow of metaphors” (41) and the lack of attention to them means
“that metaphor has returned in a distorted form—misunderstood and
capricious, even malicious” (43). Bleakley also claims that “where
guiding, leading or dominant metaphors—’didactic’—historically and
culturally shape the landscape of medical cultures and its practices,
this suggests that, reflexively, we might shift the metaphorical shaping
of a cultural landscape” (122). In other words, metaphors matter in
medicine, and Bleakley draws on a vast array of studies from diverse
fields to illustrate this point. He also admirably manages to connect the
plethora of existing metaphors in medicine with examples from poetry
and his personal experience as a teacher of medical students and as
a patient, thus providing multiple points of access to understanding
their role in medicine. The book is informed by recurring concepts
such as Mara Buchbinder’s stickiness metaphor (a metaphor used by
pediatricians to label neurobiological configurations as well as difficult
patients and their parents) and the notion of didactic metaphors, such
as illness as a battle. But Bleakley also enjoys using metaphors of his
own as explanatory devices. For example, medicine, as Bleakley claims,
is “laced with” or “oiled with” metaphor (103). Moreover, metaphors
can function as antidotes, shields or softeners, mirrors, and levers
(20). In terms of metaphor theory, the early chapters seem particu-
larly inspired by Jeffrey Donaldson’s definition of metaphor as A=B,
which Bleakley finds elegant, as well as Barbara Maier and Warren
Shibles’s concept of a “Metaphorical Method,” in which metaphors
are primarily rhetorical devices that describe relationships in medical
care, for example between health care workers and patients. It is one
of the great strengths of this book that Bleakley selects definitions,
theoretical concepts, and examples of metaphors in such a way that
each chapter’s focus throws into relief a particular challenge metaphor
poses to medicine.
Prefaced with two forewords—by physician-poet Shane Neilson and
scholar-poet Jeffery Donaldson—Thinking with Metaphors in Medicine first
maps the field of metaphor research with the aim to redeem metaphors
from ascriptions of stigmatization and harm. Chapter 1, “The Recovery
of Metaphor in Medicine,” is dedicated to this project of reclamation
and focuses on both the positive effects and inevitability of metaphors
in medicine. In its double nature as both a magnifying lens and the
thing that is being magnified, metaphor “is our primary linguistic
Book Reviews 165

medium for grasping the qualities, idiosyncrasies and expressions of

dynamic, adaptive, complex systems” (5). A metaphorical construct, such
as a virus attacking a body, gives us access to an experience of illness
by creating a paradoxical relationship between two things (virus and
attack) that are otherwise unconnected (5, 13). Chapter 2 focuses on
previous studies on metaphor in medicine, demonstrating how meta-
phors fall into disgrace when patients and researchers foreground how
some “big” metaphors, such as “the body as machine” or “medicine
as war,” thwart thinking, generate stereotypes, and lead to premature
explanations (23). Chapter 3 discusses the problems that arise when
metaphors are either discarded too soon or repressed via standardized,
“stripped-back medical language” (53), or not taken seriously when
they surface in medical slang. According to Bleakley, it is not neces-
sarily the metaphors themselves that are harmful, but the ignoring or
premature discarding of these metaphors from medical language which
is problematic in the long term. Chapter 4 traces the history of lead-
ing or didactic metaphors like medicine-as-war and body-as-machine,
locating their origins in the mid-seventeenth century and describing
their solidification following World War II. To explain their ubiquity
in medicine, Bleakley looks to Abraham Flexner’s influential model
for a more efficient, standardized, and professional medical education.
Chapters 5 and 6 are shaped by conversations with medical educa-
tor and senior pathologist Robert Marshall and focus on the aesthetic
aspects of medical metaphors, particularly on the odd pervasiveness
of sense-based food metaphors such as apple core lesions and straw-
berry tongues (74), to name but two of dozens. Bleakley interlaces
metaphors with resemblances and analogies, offering a terminological
distinction: Whereas resemblances are based on objects’ similarities,
metaphors compare and, in doing so, suggest relational structures rather
than shared characteristics (82–83). Comparisons are especially useful
for rote learning and quick pattern recognition (87). Food metaphors
in particular are often considered “medicine lite”—harmless linguistic
curiosities that are meant to make learning more fun (81). However,
Bleakley cautions, comparisons are not to be taken lightly due to the
ethical conundrum involved in associating pathological changes in the
body (which are the cause of human suffering) with aesthetic con-
cepts. As a summary of these two chapters, Bleakley provides a list
of “Nine functions for resemblances in medicine,” which range from
the pedagogical (as mnemonic triggers) to the heuristic and diagnostic.
The list also includes their function as medical-cultural and medical-
historical markers (87–101).
166 LITERATURE AND MEDICINE

Chapter 7 is dedicated to metaphors in psychiatry, a specialty

which, Bleakley argues, suffers from a “chronically anemic” vocabulary
because psychiatrists have “chosen a language of scientific objectivity”
over an understanding of language that foregrounds the expression of
subjective experiences (121–22). The psychiatric patient’s use of language,
too, can be anemic, so Bleakley argues, because psychiatric diseases
are sometimes characterized by an incapacity to grasp the metaphorical
nature of an expression: A patient with a psychiatric condition may
“take the otherwise imaginative and metaphorical world literally” (113).
Thus, in psychiatry, an ignorance of the metaphorical dimensions of
language is symptomatic of the language of both health professionals
and their patients. One cure that psychiatrists can offer, as this chapter
argues, is “a dose of metaphor”: inspired by the literary genre of magi-
cal realism, Bleakley suggests that psychiatrists need to take patients’
“fantasies seriously but not literally” (114). Thus, instead of trying to
further tame and literalize medical language, doctors should learn from
their “more florid patients” (121), asking a patient who believes that
she is poisoned whether there is “a bitterness in the poison” (122).
Bleakley’s suggestions echo similar work in psychoanalysis and psy-
chiatry, where colleagues such as Laurence J. Kirmayer and Thomas
Ogden have discussed how they work with their patients’ metaphors,
exploring with their patients alternative meanings of the metaphors on
which they seem stuck.
Chapter 8 looks at metaphors in medical education and focuses
in particular on the ways metaphors can shape how we conceptual-
ize the educational process. For example, one of the major features
of metaphors is their ambiguity, and the tolerance for ambiguity has
recently become a learning goal in approaches to medical education.
As Bleakley claims, pedagogical concepts of medical education should
be informed by metaphors of fluidity and liquidity which correspond
with concepts of “team-based, collaborative and feminine approaches”
to medical practice (139). Bleakley links these concepts to French
poststructuralist feminist theory, which supplies a number of intrigu-
ing metaphorical concepts relevant for medical practice. I would have
liked to see a more elaborate application of these theories, but the
chapter ends this discussion prematurely by repeating an earlier claim
that patriarchal, phallogocentrist notions of heroic, aggressive leading
metaphors in medicine must be challenged. However, the author’s sug-
gestion that metaphors informed by rhizomes and centrifiguality offer
intriguing alternative metaphors for medical curricula and practice is
a promising avenue for others to pursue (141).
Book Reviews 167

Chapter 9 compares medicine with poetry and further develops

the value of ambiguity in metaphors. Based on a dialogue with a
medical student who Bleakley supervised, this chapter’s major point
is that poetry and medicine both deal with the extraordinary, as well
as with the confluence of multiple and sometimes contradictory mean-
ings. Like a doctor, the poet is a diagnostician who treats culture’s
symptoms (161). This view of metaphors, in which they are sources
of imagination as well as a cure for “chronic lack of innovation, en-
trenched habits and petty-mindedness,” prepares the reader for the
two final chapters (145).
Chapters 10 and 11 are based on an international and interdis-
ciplinary symposium held in June 2016 in the UK, to which Bleakley
invited 18 scholars, practitioners, and artists to discuss the state of the
art in thinking with metaphors in medicine. Chapter 10 is a summary
of some of the papers and presentations, which is interwoven with
Bleakley’s own reflections and afterthoughts. For lack of space, I will
not go into further detail here, but I want to mention two noteworthy
contributions, namely Teodora Manea’s reflections on metaphors in
her work as an interpreter in doctor-patient conversations and Steve
Reid’s comparison of medical practice to classical music and jazz. Such
comparisons are ripe for further exploration, as they offer alternatives
to such dominant master metaphors that compare medical practice to
the work of mechanics or detectives.
Chapter 11 presents four main themes that crystallized during
the symposium: the notion that metaphors need to be understood as
existing on a spectrum, ranging from benevolent to malign; that instead
of replacing problematic metaphors with new ones, we need a multi-
plicity of metaphors; that the concepts of transparency and opacity (of
language, of medical practice, of the patient’s body) are potent new
master metaphors; and that different aspects of metaphors, namely
their non-verbal and performative qualities, deserve further attention.
Bleakley summarizes the aims of his book by advocating that
practitioners develop a “reflexive awareness of the work of metaphors,”
which can have a transformative effect on medical culture, for example
by improving patient care and safety (204). He also encourages his
readers to “embrace metaphors” and respond to them not only cog-
nitively but also aesthetically (215). Unfortunately, this latter approach
to metaphors—one that appreciates how “metaphors display beauty,
grace and impact”—comes up short in Bleakley’s study (215). Think-
ing with Metaphors in Medicine demonstrates a tendency—which can
be observed in many other studies on figurative language as well—to
168 LITERATURE AND MEDICINE

use a very broad definition of metaphor. For example, in Bleakley’s

study, “the fruit from the Tree of Life” is considered “a metaphor for
Faith” (39); however, one might also call this a symbol because, rather
than being compared to life, the fruit and the tree are standing for it.
While metaphors are indeed ubiquitous, not every figurative expres-
sion is strictly speaking a metaphor. These comments are not meant
to disparage in any way the significance of Thinking with Metaphors
in Medicine for the field of health humanities. Alan Bleakley’s book
provides both a comprehensive and in-depth understanding of the
productive work that metaphors do in medicine.

NOTES

This review was conceived as part of the research program “The Uses of
Literature” at the University of Southern Denmark (SDU), funded by the Danish
National Research Foundation (grant no. DNRF127).
Disclosure: I was eager to read and review this book as my research also
focuses on metaphors in medicine. While Alan was writing it, we were in contact via
email, and he kindly refers to my research in Thinking With Metaphors in Medicine.

—Anita Wohlmann

Andrew Mangham. The Science of Starving in Victorian Literature,

Medicine, & Political Economy. Oxford University Press, 2020. Hard-
cover, $70.00.

“Please, sir, I want some more.” Even those who have not dipped
their toes into Victorian literature are likely familiar with this line from
Charles Dickens’s Oliver Twist (1838). A famous plea for sympathy
from the novel’s orphaned protagonist, Oliver’s expressed need for
“more” indexes a larger pattern in literary representation across the
nineteenth century: a focus on starvation. Andrew Mangham’s The
Science of Starving in Victorian Literature, Medicine, & Political Economy
is the first monograph to focus on the comparatively broad subject
of extreme hunger in Victorian literature and culture, expanding be-
yond other studies’ narrower emphases on fasting, anorexia, or the
Irish Potato Famine. As the title denotes, Mangham situates literary
representations of starving bodies in relation to two nineteenth-century
cultural contexts, political economy and medical science. Through
a meticulous analysis of ample source material, from miscellaneous