THE USE OF MEDICAL METAPHORS AS REFLECTED IN THE FIELD OF ORTHO-PAEDICS AND TERMINOLOGY- A SURVEY AMONG INTERNATIONAL STUDENTS

74 Danish Scientific Journal No102, 2025 THE USE OF MEDICAL METAPHORS AS REFLECTED IN THE FIELD OF ORTHOPAEDICS AND TERMINOLOGYA SURVEY AMONG INTERNATIONAL STUDENTS Zheleva Z. Medical University of Plovdiv, Department of Languages and Specialised Training, Senior Lecturer https://doi.org/10.5281/zenodo.17740994 Abstract The present paper explores the use of metaphor in medical terminology, with a specific focus on the field of Orthopaedics and Traumatology. Metaphors, while traditionally associated with literature, are an inherent part of medical terminology facilitating not only medical communication but student learning. The study examines how metaphor facilitates the understanding and retention of complex medical concepts by mapping unfamiliar phenomena onto familiar objects, thus bridging abstract clinical knowledge with everyday experience. Drawing on key metaphor theories the paper highlights the role metaphorical expressions in the training of medical students and to what extent they use these terms appropriately and precisely. A survey conducted among international medical students at the Medical University of Plovdiv assessed the recognition and comprehension of metaphorical terms extracted from their orthopaedics and traumatology syllabus. Results revealed varying degrees of familiarity, with higher accuracy linked to visually intuitive metaphors and more common conditions. Conversely, metaphorical terms lacking vivid imagery or associated with less frequent conditions showed lower recognition rates. The findings underscore the dual role of metaphor as both a cognitive aid and a potential source of ambiguity, suggesting that while metaphoric language enhances memory and comprehension, it must be used with precision. Keywords: medical conditions, metaphor, medical terminology, orthopaedics and traumatology Language for specific purposes such as that of medicine is considered by scientists a separate language and entity possessing the features and categories of general language and yet differing from general language and consisting of “specific rules and units” (Cabre, 99, p 61). It also has distinctive characteristics due to the ‘semantic load of terminological units’ (Faber: 2012). Latin and Greek are known to be the foundational languages of medical terminologyGreek as the language of early physicians like Hippocrates and Galen, and Latin as the lingua franka in Europe for centuries. Prefixes, roots, suffixes originating from the two languages enable physicians to construct complex medical diagnoses, diseases, signs and symptoms thus revealing the role of Latin and Greek in maintaining precision and universality in contemporary medical terminology. (Mirchev, Oprova: 2018) Despite the specificities and the obviously ‘incomprehensible’ language of medicine to the general public there are certain figures which help in ‘deciphering‘ the language or making it more understandable for medical students and patients by using words and concepts which are familiar but are used in a different aspect and context. Drawing a parallel between everyday experiences and complex medical terms facilitates not only communication but learning as well. Metaphor and metonymy are two such figures which scientist would rather associate with fiction and poetry. But they play ‘a crucial part of the way in which a scientific field reproduces’ (Kuhn, 1993) entirely because the two figures are an integral part of human cognition. They participate in the creation and ‘construction’ of scientific theories. The classical view of metaphor is presented in the Aristotelian theory where metaphor is considered a rhetorical device, a matter of language, a transfer of the name of a phenomenon to another one on the basis of similarity. According to Aristotle, “Metaphor consists in giving the thing a name that belongs to something else.” (Poetics, 1457b) The focus here is on analogy and metaphor is perceived as ornamental or stylistic figure entirely unconnected to cognition. The comparison theory of metaphor relies mainly on the simile between two entities based on resemblance. “Metaphor is a compressed or elliptical simile.” (Ortony, 1979) The interaction theory of Max Black argues that metaphor is an interaction between the primary and secondary subject where meaning is created through tension. (Black, 1954) Black, Max. “Metaphor.” Proceedings of the Aristotelian Society, vol. 55, 1954– 1955, pp. 273–294. With this theory metaphor emerges as an entity which is creative, which produces new meaning and enriches the features of the secondary subject. The Conceptual Metaphor Theory claims that metaphor and metonymy are an integral part of human language and thinking present in everyday life. Metaphor is fundamental to thought and the understanding of abstract concepts is based on specific experiences. The two researchers (Lakoff and Johnson) made it clear that metaphor is not solely a literary device which we can come upon only in fiction, but they are a cognitive resource that is used in all fields of knowledge and in everyday communication. Metaphor creates and develops concepts, even whole conceptual domains, and thus underlies human behaviour and thinking. Metaphors are not just stylistic devices but conceptual tools that help people understand and structure reality through various mappings (Lakoff & Johnson, 2004). The Blending theory (Conceptual Integration Theory) of Fauconnier & Turner further expands CMT claiming that metaphor arises from intertwining many mental spaces into a new meaning. It is the blending of conceptual packets created during the use of language where novel meaning emerges. And if Lakoff and Johnson rely on fixed mappings between two domains, the Danish Scientific Journal No102, 2025 75 Blending theory involves multiple input spaces. Fauconnier, Gilles, and Mark Turner. The Way We Think: Conceptual Blending and the Mind’s Hidden Complexities. Basic Books, 2002. In the Relevance Theory Sperber & Wilson argue that metaphor is interpreted through context i.e. the listener infers the meaning which is beyond literal expression. With this theory interpretation depends on cognitive effects and processing effort and metaphors are presented as loose use of language optimized for relevance. What is interesting is the application of these theories to medical terminology and the way professionals, students and even patients conceptualise the way the body and disease work. One theory that has been increasingly applied in medical terminology is the Blending theory since it manages to combine familiar physical experiences with machine metaphors, visual models and even military logic. For example, the immune system is perceived as a defense force where attacks are mounted, cells are perceived as attackers and pathogens as invaders. Other examples are the heart, which is perceived as a mechanical pump, the kidney which is a filter and even cancer treatment which is a war. And if the purpose of this blending is to facilitate understanding and communication there are challenges which must not be overlooked, one of them is oversimplification which may mislead the listener as to the correct meaning of terms. Another disadvantage of blending metaphors is the cultural aspect and transfer of meaning in different cultures. In their book Philosophy in the Flesh, Lakoff and Johnson claim that our perception of health and illness is rooted in embodied metaphors (frameworks derived from our physical experiences) and they shape everyday language and influence medical thinking and the social attitudes towards disease. They argue that disease is often perceived as impurity or weakness, as an external force attacking the body. The idea of health is of wholeness and balance in which the body (likened to a machine) functions perfectly. Lakoff, G., & Johnson, M. (1999). Philosophy in the Flesh: The Embodied Mind and Its Challenge to Western Thought. Basic Books. Metaphor in medical terminology is used to describe entities ranging from purely anatomical parts of the body to physiological mechanisms and pathological processes. Each field and specialty of medicine is comprised of individual complex of metaphorical images and concepts. In medicine, metaphors are employed not only to improve understanding but also to aid students in retaining information as part of the learning process. (Masukume 2012:55). Medical metaphor has colour e.g. ‘blue ear’, human quality- “wisdom tooth”, it uses animals – ‘leopard skin’, fruits – ‘pear-shaped bladder’, food- ‘pancake cells’, plants-‘oak leaf spots’, clothing- “kneecap”, it is even eponymous “Medusa head”. These sources of terminology aim at denoting and associating familiar images and phenomena to pathological conditions, appearances and even forms. Metaphorical images not only aid in communication, but they also broaden our understanding of health and disease. This article pays particular attention to those medical metaphors which are used in the field of Orthopaedics and Traumatology. Those terms denote diseases, symptoms and even treatment methods and are formed by a familiar word, an animal, even a deity and a medical term thus facilitating students’ understanding and memorization. However, the main aim of the paper is to show to what extent students use these terms appropriately, and to what extent the metaphorical terms manage to convey the full meaning of the medical term. The metaphorical images created the combinations -dancing patella, butterfly-like fracture, parrot’s beak, pigeon breast, tibia yatagansound peculiar and are somewhat colloquial, however this is done for the sole purpose of development and dissemination of medical knowledge. In this way medical terms become more comprehensible and easier to remember than the Latin/Greek source that lies behind them. In this way, metaphor serves as a bridge between the clinical and the cognitive, between the scientific precision of Latin or Greek terminology and the learner’s need for tangible association. The medical terminology and especially the Latin and Greek terms and term elements present a challenge to medical students throughout the world (Mirchev, D., Oprova , Ya. (2024). And the mistakes in using it are not few, even diagnoses in the health legislation are mistakenly used in countries like Bulgaria where Latin is the language of medicine (Mirchev, D., Oprova , Ya. (2023). For the purposes of the survey on the use of metaphorical medical terminology from the fields of Orthopaedics and Traumatology a questionnaire with ten questions on different metaphorical terms from the above-mentioned specialties were excerpted from the obligatory textbook for the Orthopaedics and Traumatology course at Medical University of Plovdiv. The course is part of the curriculum for medical students in year 4 and 5 so the target group of respondents were international students with English as a language of training who have completed the course or ones who were studying it at the time of the dissemination of the questionnaire. The total number of respondents is 52. Each question has three possible answers but only one correct, the rest of the answers are partially correct or misleading. 76 Danish Scientific Journal No102, 2025 Table 1. Results from the survey: Question Option A Option B Option C Correct Answer % Correct Q1dancing patella 23 (45%) 27 (53%) 1(2%) B 53% Q2duck-like gait 1(2%) 38 (73%) 13 (25%) B 73% Q3Minerva cast 19 (37%) 2(4%) 31 (60%) C 60% Q4marble bone disease 35 (67%) 16 (31%) 1 (2%) A 67% Q5tibia yatagan 37 (73%) 8 (16%) 6 (12%) A 73% Q6froggy position 35 (69%) 6 (12%) 10 (20%) B 12% Q7parrot’s beak form 5 (10%) 40 (78%) 6 (12%) B 78% Q8 – butterfly-like fracture 13 (25%) 13 (25%) 26 (50%) C 50% Q9pigeon breast deformity 0 (0%) 2 (4%) 50 (96%) C 96% Q10Clubfoot deformity 51 (98%) 1 (2%) 0 (0%) A 98% This survey reveals considerable variability in accuracy. The percentage of correct responses ranged from 12% to 98%, highlighting areas of both strength and weakness in the knowledge of orthopaedic and traumatological terms. The highest performance of 98% was observed in Question 10, which assessed the knowledge of clubfoot deformity. This achievement is likely to reflect the strong emphasis paid to the condition during training in orthopaedics and traumatology course. The visual similarity of the condition with the metaphorical nomination has obviously facilitated memorization of the condition. Another metaphorical term of which students have excellent awareness is pigeon breast deformity (pectus carinatum) - Question 9 - 96% of the respondents gave a correct answer. The visual analogy created with this term is another evidence of the role of dual coding (visual + verbal processing) which is an effective tool for learning [Paivio, 1991]. A high performance was observed in Question 7, concerning the parrot’s beak appearance sign, a radiographic sign associated with osteoarthritis (78% correct). Similarly, high accuracy was noted for duck-like gait (Q2) and tibia yatagan deformity (Q5), each with 73% of students selecting the correct response. These findings suggest that conditions with distinctive clinical or radiographic features especially those described by metaphoric imagery may be better memorized and used due to their diagnostic clarity or frequency of exposure during training. Dual codingthe process of linking verbal information with visual imagery facilitates learning by involving verbal and non-verbal cognitive domains. [Paivio 1991; Cook et al. (2008).]. The metaphoric conceptual information transferred from the familiar objectsbirds and a weapon (yatagan) onto the medical conditions has facilitated the learning process since the terms map unfamiliar phenomena to familiar entities from everyday language. For example, the parrot’s beak invokes the curved bone form characteristic of osteoarthritic changes seen on radiographs. Similarly, in tibia yatagan deformity the curved bone which occurs as a complication of syphilis of the bones shares a striking resemblance to the Turkish weapon. Metaphoric terms enable learners, physicians and patients to create mental schemas and associative links in order to comprehend complex pathologies. However, with these terms oversimplification is a risk which should not be underestimated. For instance, 25% of the respondents to Question 2 (on duck-like gait) have mistakenly marked as correct just one aspect of the condition related to the characteristic walking difficulty omitting the other characteristic signsmall steps. This illustrates a potential drawback of metaphoric terms: they may highlight pronounced features while masking other signs and symptoms which leads to incomplete conceptual understanding. Therefore, attention should be paid as to the complete clinical description of these terms otherwise diagnostic precision could be impacted. Furthermore, moderate correct response rates (60% and 67%, respectively) are found with Question 3, on the application of the Minerva cast for cervical spine immobilization, and Question 4, regarding marble bone disease (osteopetrosis). These findings indicate intermediate familiarity, likely due to the rarity of these conditions and the limited experience students have with them. The eponymic term does not evoke an immediate visual representation of the cast so a lower response rate of correct answers is expected. The metaphoric expression marble bone is easier to imagine, but the insufficient knowledge of the disease may interrupt correct usage. However, these results reinforce the need for exposure to less common but clinically significant conditions, as emphasized in competency-based medical education frameworks [Frank et al. (2010).]. Similarly, Question 1, testing the understanding of the dancing patella sign (a clinical indicator of knee joint effusion), yielded a correct response rate of 53%. Although this sign is a common finding in the clinical setting and widely taught, the terminology may not be consistently reinforced, particularly outside formal training setting. The metaphorical term describes the irregular movement of the kneecap when fluid is present Danish Scientific Journal No102, 2025 77 in the knee joint. However, the lack of direct visual representation and limited vividness of the metaphor may be the cause for the moderate response rate. The sign’s name might be remembered but not fully understood thus contributing to students’ partial recall. [Stanley D, McCarthy S. (2003).]. Question 8—on the butterfly-like fracture— showed a moderate correct response rate of 50%, with equal distribution among the distractors (25%, 25%, 50%). Despite employing metaphor, the term butterfly fracture may not be as immediately recognizable in terms of medical meaning and traumatological condition. The structure and form of the fracture may be too complex and not directly related to image of a butterfly to students or probably the lack of clinical experience is the factor which hinders learning. The evenly distributed responses suggest conceptual ambiguity and a lack of strong associative learning, indicating a need for more effective imaging-based training or inclusion of more practically oriented tasks for memorizing terms. On the other hand, the lowest correct response rate was seen in Question 6 on the froggy position—a postural sign in developmental dysplasia of the hip (DDH)—with only 12% of participants selecting the correct answer (adduction and extension). The distractors abduction, rotation, flexion (similar terms related to movement) are the likely reason for the students’ confusion. Despite the inherently metaphoric term froggy position and its visual similarity to that of a frog, it has not evoked the correct response for most students. This may suggest that the metaphor alone was not sufficient without the appropriate medical context, so it has been interpreted inconsistently. The results may also reflect another issue in medical education - paediatric orthopaedic signs are often underrepresented in undergraduate general orthopaedic syllabi leading to limited knowledge of the medical terminology [Smith et al. (2014).]. The variability in performance highlights the importance of targeted curricular training strategies. Performance was highest with familiar, easy to imagine terms such as clubfoot and pigeon breast deformity in which cognitive links are easily created thus supporting student learning. On the other hand, lower performance on other metaphorical terms (froggy position and butterfly fracture) were more difficult to learn due to limited clarity, rare occurrence or lack of clinical association. Therefore, methodological strategies for mastering medical terminology should not rely on metaphoric terms but rather employ visual aids, clinical application and practical training particularly for less common and more complicated conditions. In conclusion, despite the fact that metaphor serves as a valuable pedagogical tool offering vivid imagery and creating unusual terms in a field characterised by complex terminology and diagnostic precision, it must be approached with careful consideration. Metaphorical term usage can enhance memorisation and comprehension; however, it is characterised by ambiguity, lack of precision etc. The skill to understanding and apply metaphorical structures in medical language is essential not only for students, but for translators, terminologists, and medical professionals as well as it connects language, science, and perception. Nevertheless, a tension between the figurative nature of metaphor and the precision of medical language exists. Therefore, while metaphoric terms can support learning and communication, their effectiveness depends on contextual precision, clinical experience and practical application. References: 1. Aristotle. Poetics. Heath M, translator. London: Penguin Classics; 1996. 2. Brazhuk Y. The sources of metaphorization and peculiarities of the metaphorization process in medical terminology. Sci Educ New Dimens Philol. 2017;118. 3. Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Instructional design variations in internet-based learning for health professions education: a systematic review and meta-analysis. Acad Med. 2008;83(5):495–503. 4. Epstein RM. Assessment in medical education. N Engl J Med. 2007;356(4):387–96. 5. Faber, Pamela (ed.). 2012. A Cognitive Linguistics View of Terminology and Specialized Language. Berlin, Boston: De Gruyter Mouton. 6. Frank JR, Snell L, ten Cate O, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638–45. 7. Gupta N, Varma M, Kumar TP. Parrot’s beak sign in brucellosis. QJM. 2025. doi:10.1093/qjmed/hcaf106 8. Kuhn TS. Metaphor in science. In: Ortony A, editor. Metaphor and Thought. 2nd ed. Cambridge: Cambridge University Press; 1993. 9. Lakoff G, Johnson M. Metaphors We Live By. Chicago: University of Chicago Press; 1980. 10. Masukume G, Zumla A. Analogies and metaphors in clinical medicine. Clin Med (Lond). 2012;12(1):55–6. doi:10.7861/clinmedicine.12-1-55 11. MedlinePlus [Internet]. Walking abnormalities. [reviewed 2023 Jan 23; cited 2025 Jun 2]. Available from: https://medlineplus.gov/ency/article/003199.htm 12. Mirchev, D., Oprova, Y. (2023). Errors in the use of medical terminology in Latin in the regulatory framework of the Republic of Bulgaria. In Tenth International Scientific Conference “Language, Science, Communications and Sport – 60 Years of Academic Education”: Collection of Papers (Volume 2, ISBN 978-619-221-452-4) Varna: Publishing House of the Medical University – Varna. 13. Mirchev, D., Oprova, Y. (2024). The eternal significance of the Latin language for science. Contemporary challenges in teaching Latin with medical terminology and regulatory framework. In First National Scientific Conference with International Participation “Language and Science”: Collection of Papers (ISBN 978-619-237-129-6). Plovdiv: Publishing House of the Medical University – Plovdiv. 14. Nicol DJ, Macfarlane‐Dick D. Formative assessment and self‐regulated learning: a model and 78 Danish Scientific Journal No102, 2025 seven principles of good feedback practice. Stud High Educ. 2006;31(2):199–218. 15. Oprova, Ya., Mirchev, D. Terms for medicine and treatment in Latin and Greek terminology, Collection of articles, Plovdiv, 2018, ISSN: 978-619-237013-8.Oprova, Ja., Mirchev, D. Termini za lekarstvo i lechenie v latinskata i gr"ckata terminologiJa, Sbornik statii, Plovdiv, 2018, ISSN: 978-619-237-013-8. 16. Ortony A, editor. Metaphor and Thought. Cambridge: Cambridge University Press; 1979. 17. Paivio A. Dual coding theory and education. In: Kozma RB, editor. Learning with Media. Hillsdale, NJ: Lawrence Erlbaum Associates; 1991. 18. Skelton JR, Wearn AM, Hobbs FR. A concordance-based study of metaphoric expressions used by general practitioners and patients in consultation. Br J Gen Pract. 2002;52(475):114–8. 19. Smith T, Crocker J, Dodd K, Richards SH. Teaching pediatric orthopaedics: is it adequately covered in undergraduate medical curricula? J Child Orthop. 2014;8(2):123–9. 20. Stanford Medicine 25. The knee exam. Stanford University School of Medicine. Available from: https://med.stanford.edu/content/sm/stanfordmedicine25/the25/knee.html 21. Stanley D, McCarthy S. Clinical tests for knee effusion: a systematic review. Physiotherapy. 2003;89(3):162–9. 22. Stavrev P, Atanasov A. Orthopedics and Traumatology. Plovdiv; 2004. Stavrev P, Atanasov A. OrtopediJa i TravmatologiJa. Plovdiv; 2004. 23. Stavrev V. Orthopedics for Medical Students. Plovdiv; 2012. 24. Stavrev V. Traumatology for Medical Students. Plovdiv; 2012. 25. Usyk G, Kyrylenko T. Метафора як спосіб утворення медичної термінології [Metaphor as a way of terms coinage in medicine]. Adv Linguist. 2020;(5):62–7. doi:10.20535/26175339.2020.5.203922 26. Yefimova OS. Metaphorization as a source of emergence of some medical terms. Russ Linguist Bull. 2024;2(50).