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In a previous installment of this series (Vol. 26, No. 4), 

I urged writers and editors to consider whether each 

of the subject-verb and subject-verb-object relation-

ships expressed in their sentences is literally true. In medi-

cal writing, we deal mainly with facts. Thus, most of what 

we write should be literally true. However, it is sometimes 

acceptable and even necessary for medical writers to use 

figurative language, such as metaphors and metonyms, 

that don’t express literal truth. Scientists use metaphor and 

analogy to make sense of the world and to express their 

ideas to others. For this reason, scientists often use meta-

phors in their writing. 

Literal or Figurative Language
The word literal comes from the Latin word literalis, which 

means “of or belonging to letters and writing.” It came to 

mean “according to the exact meaning of the word” (eg, the 

word’s dictionary definition). In contrast, the word figurative 

refers to figures of speech. A figure of speech is any deviation 

from literal meanings or common usage. This could mean 

using some deviation from ordinary grammar or word order, 

or it could mean using a word to mean something other than 

its customary meaning. Shakespeare often used figurative 

language to express intense emotion: 

But soft, what light through yonder window breaks?

It is the east, and Juliet is the sun.

Arise, fair sun, and kill the envious moon,

Who is already sick and pale with grief

That thou, her maid, art far more fair than she.

—William Shakespeare, Romeo and Juliet, Act 2, Scene 2

 To understand such a poetic passage, it is helpful to 

create a paraphrase, which is a restatement of the meaning 

of a text or passage in different words. Here’s how Romeo’s 

speech would sound if stripped of its figurative language: 

I see Juliet through her window. She is more beautiful 

than her cousin Rosaline, who should be jealous of her. 

 This paraphrase captures the literal meaning of Romeo’s 

speech but fails to express the intensity of his infatuation. 

Romeo had previously been smitten with Juliet’s cousin, 

Rosaline: “The all-seeing sun / ne'er saw her match since 

first the world begun.” But now, he is saying that Juliet is  

the sun. 

Metaphor
A metaphor is a figure of speech in which a word or phrase 

(eg, the sun) is applied to an object or action to which it is 

not literally applicable (eg, Juliet). The word metaphor comes 

from the Greek for to transfer. In a metaphor, some attributes 

are being transferred from a figure (also called a vehicle) to 

a ground (also called a tenor). In one of Romeo’s metaphors, 

the sun is the figure and Juliet is the ground. In another, he 

calls upon the sun to kill the moon. That command contains 

3 figures (sun, kill, and moon) and 3 grounds (Juliet, dis-

place, Rosaline).

 Many scientific terms started as metaphors. For exam-

ple, Robert Hooke used the word cell, which literally meant 

a small room, to refer to the microscopic structural units he 

saw in plant tissue. The so-called cells in plant and animal 

tissue are not literally rooms, just as Juliet is not literally the 

sun. Nevertheless, the word cell came to be the official  

name for the smallest structural and functional units of all 

living things. 

Extended Metaphor
Once Romeo has established that Juliet is, metaphorically 

speaking, the sun, he can use the moon as a metaphor for 

some lesser woman. Thus, he is using an extended metaphor, 

which is a metaphor that sets up several subsidiary subjects 

or comparisons. 

Mixed Metaphor
A mixed metaphor (sometimes playfully called a mixaphor) 

is one that leaps from one identification to a second identi-

Metaphorically Speaking
Laurie Endicott Thomas, MA, ELS / Madison, NJ



46    AMWA Journal / V36 N1 / 2021 / amwa.org        

fication that is inconsistent with the first. Merriam-Webster’s 

dictionary offers this one: 

If we want to get ahead, we’ll have to iron out the remain-

ing bottlenecks.

 You use an iron to smooth out wrinkles, not to remove  

bottlenecks. 

 Mixed metaphors can be confusing. Sometimes, they are 

used for comical effect. Avoid them unless you are a profes-

sional comedian.

Dead Metaphor
The expression dead metaphor is itself metaphorical because 

a metaphor is never literally alive. A dead metaphor is a meta-

phor that has lost its metaphoric force through common usage. 

In other words, it is no longer a figure of speech. Many tech-

nical terms, such as the word cell, started as metaphor only 

to become standard terminology. Once the biologists’ defini-

tion of the word cell was added to the dictionary, the use of the 

word cell to refer to 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. A metaphor is really most sincerely 

dead if its original meaning has been forgotten. For example, 

a mainstay was originally the rope or wire that held the ship’s 

mainmast in position. Today, few people know the terms for 

nautical rigging. However, they commonly use the word  

mainstay to mean something on which someone or something 

depends (eg, rice is the mainstay of the diet in much of Asia). 

Metonym
Metaphors are often confused with metonyms. A metaphor 

creates a new link between 2 concepts from separate concep-

tual domains (eg, Juliet belongs to the domain of humanity 

and the sun belongs to the domain of astronomy). In con-

trast, a metonym relies on an existing conceptual link. For 

example, people in the United Kingdom, Canada, and other 

Commonwealth realms often use the word crown to refer to the 

monarch (who occasionally wears a crown) or to the national 

government in general. 

Simile
A metaphor is an implied comparison, often made by using 

a linking verb to connect ground with figure (eg, Juliet is the 

sun) or by simply referring to the figure in a way that suggests 

the ground, such as by using the phrase “the elephant in the 

room” to refer to an obvious problem. In contrast, a simile is an 

explicit comparison of 2 unlike things, typically by using words 

such as as, like, or than. However, not all comparisons are sim-

iles. Similes take the grammatical form of a literal comparison 

but express something that is not a statement of fact: 

My love is like a red, red rose. 

—Robert Burns

Clichés
Some metaphors and other figures of speech are so over-

used that they become clichés. A cliché is an overused phrase 

or opinion that betrays a lack of original thought. Examples 

include “crystal clear” and “cool as a cucumber.” Some clichés 

are metaphors, and some are not. 

•  She dangled a carrot in front of his nose. (metaphor)

•  The explanation was as clear as mud. (simile)

Figurative Language in Medical Writing
There are no unbreakable rules for using figurative language  

in medical writing. On the one hand, medical writers are 

mainly concerned with conveying facts and truth as opposed 

to expressing emotion artistically. Thus, medical writers 

should be cautious about using figurative language, especially 

when their audience includes poor readers or non-native 

speakers of the writer’s language or if the text is going to be 

translated. On the other hand, a large proportion of the tech-

nical vocabulary used in medical writing consists of dead  

metaphors, such as the word cell, as well as metaphors that 

are not quite dead yet. 

 There are several good reasons for using figurative lan-

guage in medical writing. One is to help your readers under-

stand some complicated system or relationship. To do that, you 

may draw an analogy to something that they already under-

stand or that you can at least explain. For example, many of the 

terms used for talking about how cells communicate with each 

other came originally from radio (eg, signal, amplification, 

gain, feedback). These terms were originally metaphors but 

lost their metaphorical force through common usage among 

cell biologists. 

 Another reason for using figurative language is conve-

nience. For example, evolutionary biologists often talk about 

the evolutionary strategies of bacteria, plants, and lower ani-

mals. This use of the term strategy is a dead metaphor. It is a 

metaphor because the “strategies” in question do not repre-

sent anything that an organism is consciously choosing to do. 

Evolutionary strategy is a dead metaphor because the diction-

ary already tells us that the word strategy can mean an adap-

tation or set of adaptations that contribute to evolutionary 

success. Among microbiologists, the word strategy is a short-

hand for that concept. 

 Shorthand is itself a dead metaphor. Shorthand origi-

nally meant a method of rapid writing that involved abbrevia-

tions and symbols. Thus, a shorthand came to mean a short 

and simple way of expressing or referring to something. Some 



AMWA Journal / V36 N1 / 2021 / amwa.org    47

members of a lay audience may not understand that an 

evolutionary strategy is not something that the organisms 

are planning to do. So, depending on your intended audi-

ence, you may have to avoid using a shorthand or at least 

explain what the shorthand means. 

 Metonyms can also be used in medical writing, albeit 

cautiously. For example, the word practice is often used as 

a metonym to refer to a type of business in which a medi-

cal practitioner or group of practitioners provide care to 

patients. So, you might use the term “the practice” when 

you want to refer to such a business as a business or when 

you don’t want to specify a particular part of the business. 

For example, you could encourage patients to “contact the 

practice” without specifying which person or even which 

office to contact. Your goal should be clarity. If the patients 

can contact any member of the staff, you can urge them to 

contact the practice.

 In general, you may wish to avoid unnecessary use  

of figurative language in a technical report, such as a 

clinical study protocol—especially if it is going to be 

translated. However, there is considerably more room for 

literary inventiveness in an opinion piece. In such pieces, 

authors may wish to express their own emotions and to 

evoke emotions in the audience, especially to underscore 

the importance and urgency of their message. In that  

situation, the writer may use figurative language for  

rhetorical effect. 

Learn More
Metaphors, similes, and metonyms are not the only 

forms of figurative language. The Silva Rhetoricae Web 

site (http://rhetoric.byu.edu/), maintained by Dr Gideon 

Burton of Brigham Young University, provides an extensive 

list of figures of speech, all of which are named, defined, 

and categorized. Many of these rhetorical figures have 

Greek or Latin names because they have been recognized 

since classical times to be valuable in persuasion. 

Author declaration and disclosures: The author notes no commer-
cial associations that may pose a conflict of interest in relation to 
this article.

Author contact: www.nottrivialbook.com; lthomas521@verizon.net 

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