Illness, metaphor and pathography

ILLNESS, METAPHOR AND PATHOGRAPHY Arran Stibbe Introduction The study of metaphors of illness has become almost a sub-discipline in itself within the larger discipline of medical sociology. Sontag (1979) initiated the subdiscipline with her passionately written polemic Illness as Metaphor. However the studies which followed Sontag’s seminal work were no doubt spurred on by the revolution in metaphorical theory originated by Lakoff and Johnson (1980). In Metaphors we live by, Lakoff and Johnson placed metaphor at the centre of human cognition, governing ‘our everyday functioning, down to the most mundane details’ (p1), and since then they have developed their theory into the predominant contemporary theory of metaphor (see Lakoff and Johnson 1999). This revolution, combined with a general post-modern re-examination of the ‘truths’ of science, including medicine, has led to much closer attention being paid to the social construction of illness within the world of medical science. The main reason that the analysis of metaphor has become such an important part of medical sociology is the possibility that metaphor can influence reasoning. As Lakoff and Johnson (1999) say, ‘perhaps the most important thing to understand about conceptual metaphors is that they are used to reason with’ (p65). Goatly (1997:155) goes as far as to speak of the ‘impossibility of non-analogical reasoning’. Reasoning leads to decisions, and, in a medical setting, clinical decisions are of crucial importance. Every day doctors, nurses, and patients themselves make decisions which have an impact on the patients’ health. Any of these decisions could be influenced by metaphorical reasoning. For example, May (1983:100) suggests that the metaphor of doctor as technician may influence the reasoning pattern of doctors to make decisions which ‘bring lab values within acceptable limits’ rather than taking patients’ general needs into consideration. A metaphor of the body is a machine might influence doctors to decide to treat malfunctioning parts rather than searching for a general underlying cause (Kirmayer 1988). Arguments along the same lines have been made about the metaphors of doctor as fighter, curing illness is sport, illness as a puzzle, and illness is punishment, by Gray and Doan (1990), Stein (1990), Deikema (1989) and Sontag (1989) respectively. This paper, however, focuses not on the clinical decisions made by doctors, but on the more neglected world of the patient, and the effects of metaphors on how patients, and the relatives caring for them, think and reason about their illness. I shall be arguing that an approach which combines a theoretical framework of metaphor with a close analysis of patients’ own accounts of their illness can provide insights into the complex workings of metaphor in the lives of patients. After a discussion of theoretical aspects of metaphor and reasoning, this paper gives an illustrative case study of metaphors used in the care of AIDS patients. Theoretical considerations According to Lakoff and Johnson (1999:155), metaphorical reasoning is ‘the principle instrument of abstract reason, the means by which the inferential structures of concrete domains are employed in abstract domains’. Lakoff and Johnson’s theory is based on the idea that a vague target domain is structured along the lines of a much more concrete source domain. For example, the complexities of the human body (target domain) could be structured in terms of the much more tangible and understandable structure of machines (source domain), according to a body is a machine metaphor. Metaphorical reasoning occurs when reasoning about the target domain uses knowledge which derives not from the target domain itself, but from the source domain, by a process of metaphorical entailment. As an illustration, Johnson (1987:131) claims that medical science was influenced by the body is a machine metaphor, since facts from the source domain of machines were being applied to reasoning about the causes of illness in humans. This includes the fact that, for machines, ‘breakdown consists in the malfunctioning of parts’. According to Johnson, applying this to humans caused medical science to overlook underlying causes of illness such as stress, and focus instead only on the malfunctioning parts of the body. Johnson (1983:371) calls understandings of the target domain which come directly from facts belonging to the source domain ‘metaphorical entailments’, or ‘entailments’ for short. For example, if ‘a machine consists of distinct, though interconnected parts’, and the metaphor the body is a machine is used, then this metaphorically entails that ‘the body consists of distinct, though interconnected parts’ (Johnson 1987:130). If reasoning is based on such entailments, then it is being influenced by metaphor, and it is this use of facts from the source domain in thinking about the target domain which forms the basis of metaphorical reasoning. It follows, therefore, that different metaphors and entailments lead to different reasoning patterns, and hence different decisions. At this point an important question, and the central question of this paper, arises. Of the unlimited number of facts about the source domain which could potentially be drawn upon to reason about the target domain, exactly which facts are used and which ignored? Johnson lists several entailments about the human body which potentially arise from the body is a machine metaphor. These are as follows: The body consists of distinct, though interconnected parts. It is a functional unity or assembly serving various purposes. It requires an energy source or force to get it operating. Breakdown consists in the malfunctioning of parts. Breakdowns occur at specific points or junctures in the mechanism Diagnosis requires that we locate these malfunctioning units. Treatment directs itself to specific faulty units or connections. Repair (treatment) may involve replacement, mending, alteration of parts, and so forth. Since parts causally interact, we must be alert for failures in causal connections. The parts of the functioning unity are not themselves self-adapting. But the number of facts about machines that we could write down in this form is endless, and in any particular instance of the body as a machine metaphor only a small subset is used. One fact that is unlikely to be used is the following: The more a machine is used the more likely it is to wear down. If this was applied to human beings it would imply that the more exercise we do the sooner we wear our bodies down, which is, in fact, quite the reverse. If doctors drew this fact out of the source domain and used it in the target domain they would be recommending that people should not do exercise. This is a very unhelpful idea and therefore this particular entailment is not used. A fact such as ‘repair may involve replacement’, however, may be useful if applied to humans with internal organ problems, where organ replacement has proved an effective therapy in many cases. The fact ‘treatment directs itself to specific faulty units’ might also be helpful for doctors, since applying it to humans simplifies the doctors task, reducing the stress involved in searching for a subtle, general cause of a local problem. What I am suggesting is that people use particular entailments from the source domain because they are helpful in particular situations, and exactly which entailments are drawn out depends on the situation, as well as the aims and goals of the individual. The specific implication of this for studies of metaphors of illness is that when analysing metaphor it is not sufficient to simply identify the source domain and target domain and make conclusions about how the source domain is likely to effect the target domain. It is impossible to know exactly which facts from the source domain are being used in a particular situation. Instead, it is necessary to look at textual evidence to determine which specific entailments are being used, and then to analyse the effect of these entailments. To illustrate this, consider the following example, from Ross (1989:40): ‘Indeed, in the ‘war on AIDS’ metaphor, the concrete reality of thousands and ultimately millions of sick people in need of medical care and social and emotional support is entirely lost sight of, primarily because there is no important role for the sick in a war. This makes war a poor metaphor for AIDS public policy.’ In this statement Ross appears to be blaming the metaphor for the plight of AIDS victims. However, there are an infinite number of facts about war which could be applied to thinking about AIDS, such as ‘in wars, the enemy will not go away if ignored’. The question is, exactly which facts about war are being drawn on by the government? And is there any specific (eg, textual) evidence of the US government using the fact that ‘there is no important role for the sick in a war’ in their reasoning about how to treat people with AIDS? If there is such evidence then it is important to realise that this fact about the source domain was selected from an unlimited number of alternative facts that could have been chosen. Choosing a particular fact and applying it to reasoning about the target domain is therefore something which can be influenced by the situation and goals of the people using the metaphor, rather than being an inevitable result of using a particular metaphor. In this case, if politicians selected the fact that ‘there is no role for the sick in a war’ from all possible facts about warfare, and then applied it their reasoning about AIDS policy, then this may be based on personal goals such as protecting their social group or themselves from infection at the expense of people who are already sick. It seems to be the case that of the many alternatives available, individuals chose metaphors and entailments which influence their reasoning patterns in ways that tend to give results which fit their aims and goals. There are, however, particular metaphors and entailments that are commonly used within a culture, and can easily be picked up by people and used in their thought. These are the conventional metaphors that Lakoff and Johnson describe, and there are also conventional entailments that people tend to draw (Lakoff and Johnson 1980:53). However, even within conventional metaphors there is usually a choice of several different commonly used metaphors and entailments, and patients are not restricted to using only these in their thought processes. When we come to an analysis of the influence of metaphor in the lives of patients and their relatives there are two fundamental questions: The first, and most obvious, question is ‘which metaphors are patients using?’ The second is ‘how are the metaphors influencing their reasoning?’ To answer this question, I have argued that it is necessary to determine which specific facts from the source domain are being transferred and used in reasoning about the target domain. Investigating entailments using pathography Metaphor, as Lakoff and Johnson define it, is not a characteristic of language, but of thought. The metaphorical process, where patients structure their illness using a variety of metaphors, and think and reason based on these metaphors, is something that is going on inside their minds. One way to get insight into the thought processes of patients and their relatives is to analyse pathographies, that is, autobiographical novels written by patients (or the people caring for them) about their illness. The metaphors patients use to think about their illness inevitably find their way onto the page when they try to convey to the rest of the world what their illness means to them. Since the patient’s choice of entailments (and metaphors) depends on their situation, personality, aims and goals, pathography provides many of the background details necessary to fully understand the metaphors. Furthermore, the effects of metaphorical thinking may occur a long time after the metaphors are first used, and pathography helps to give a longer term view of the effects of metaphorical thinking. Pathography has tended to be neglected both by literary critics and medical sociologists, with the notable exception of Anne Hunsaker Hawkins (1993), whose book Constructing Illness and numerous papers provide a great deal of insight into what it means to be ill. Hawkins (1993:14) points out, however, that pathographies ‘cannot be taken as accurate records of experience: they are too highly charged, as the ambivalence and prosaic quality of everyday living is resolved into sharp contrasts and clear cut issues’. On the other hand, Jones (1984:257) points out that statements such as this could ‘cause some readers to infer that autobiographical pathography is more fiction than fact’, and argues for the opposite, pointing out that while all writing goes through the process of selection and arrangement, ‘that does not mean that all writing is fiction’. But whether fiction or fact, the analysis of metaphorical thought processes in pathography could be considered to be an investigation into the metaphors in the minds of the writers as they were writing, as evidenced by the text that they produced. Analysis of such metaphors is still useful for the ultimate goal of this kind of study (i.e., helping patients and their relatives to find helpful ways of thinking about their illness based on the experience of others). The analysis of pathography suggested in this paper consists of the identification of metaphors, identification of the source and target domain, analysis of which facts from the source domain are being transferred to the target domain, and analysis of what effects these seem to have on reasoning patterns. This kind of analysis is illustrated in the small case study below on metaphors of AIDS. Illustrative study: Fighting, war and AIDS This study presents a brief analysis of metaphors of fighting and war in the experience of AIDS, looking mainly at the pathography In the Absence of Angels by Elisabeth Glaser (1991), but also mentioning two other similar pathographies (Monette 1988 and Doty 1996). These books were not written by the patients themselves, but by family members caring for them. As Hawkins (1993:3) points out, such biographical pathographies are written by someone very close to the patient, and thus ‘override the conventional boundaries of self and other or biographer or subject’. Both carer and patient are dealing with the illness, and the metaphors that the carer uses to think about the patient’s illness can have an impact not only on the patient’s thinking, but also on their treatment decisions. Glaser’s use of fighting metaphors On the cover of Elizabeth Glaser’s book, In the Absence of Angels, there are the words ‘One family’s courageous fight for survival’. This metaphor, of dealing with illness is a fight, is one that runs throughout the book, and appears to structure Glaser’s whole way of thinking, reasoning and dealing with AIDS. The fight started when Glaser was given seven pints of blood after the birth of her daughter, Ariel: ...suddenly realising that I might die in that room, I began fighting back for my life. (Glaser p9) That fight was for her own life, but four years later the fight for her daughter’s life began: Without even knowing what was wrong, I was fighting for her [Ariel’s] life. (p38) Glaser and her son were found to be HIV positive, and her daughter had full blown AIDS. The blood transfusion had been contaminated. From the time that her family was diagnosed as having AIDS, much of Glaser’s life seems to have been structured in terms of a fight, or rather many fights, battles and wars. She describes fighting for her daughter’s life, for her son’s life, for her own life, against AIDS, against the virus, against time, against being in hospital, against pain, and against fear and discrimination. In the following few sections I discuss which facts from the source domain of fighting Glaser uses in her reasoning about AIDS, and the consequences which seem to have arisen from these uses of the metaphor. The source domain of a fight Source domains are made up of a number of elements, some of which are compulsory and some optional. In the case of a fight, compulsory elements are the fighter and an enemy. Voluntary elements include such things as weapons, allies, and a precious object over which the fighters are fighting. Within a metaphor such as dealing with illness is a fight, the target domain, dealing with illness is structured in terms of the source domain, a fight. Metaphorical reasoning consists of facts from the source domain being used to think about the target domain. There is an unlimited number of potential facts about the source domain (a fight) such as the following: A fight has winners and losers. In a fight attention is focused on winning. The strongest, most skillful side wins. A fight can be a frightening experience By analysing the pathography of Elisabeth Glaser, it is possible to get an idea of which facts about the source domain she uses, and how they influence her thinking. Facts taken from the source domain of war Fact 1: Fighters are strong By thinking of herself and her daughter as fighters or warriors, and by choosing to fight, Glaser seems to be finding reserves of strength and energy, and a feeling of power: I was too much of a fighter and Ariel had just as much spunk. We would show them we could beat it [AIDS]. I could run and hide, or I could stay and fight. And in having and making a choice, I was, in fact, empowering myself. (p280) This comes from facts about the source domain of fighting such as ‘In a fight, the fighters summon up energy and resources to devote to the fight’. Also, the very fact that someone is fighting means that they have some strength, because of the prerequisite of strength that is necessary to fulfil the role. It is understandable that Glaser draws on facts related to strength, since she clearly values the feeling of strength. Fact 2: Fighters are not victims The strength that goes along with fighting is incompatible with the idea being of a victim, and clearly Glaser views the role of victim with distaste: I had a new strength because now I was so angry that I had stopped being a victim. (p115) The source domain that ‘victim’ comes from is very much like that of a fight, except that the enemy is so powerful that no resistance can be made. However, Glaser rejects the metaphor of victim, since apart from the fact that ‘victims are innocent’ (often drawn out and used by the gay community), facts about victims such as ‘victims are weak’, ‘victims have no chance of winning’ do not fit Glaser’s personality and outlook. Instead, she views herself as a warrior: He talked to me about being a warrior. I felt like one. When you move through the world as a family with AIDS you have to be ‘hyper-alert’ and as vigilant as a point man. (p64) However much someone draws on the fact of ‘fighters are strong’, however, there is always the reality, where patients are often weak. This contradiction, and the disappointment it can lead to, can be seen in the following quote: She [Ariel] was a valiant fighter but was only able to finish two weeks of first grade at Crossroads. (p89) Fact 3: Fighting requires a focus on winning In Stibbe (1997) I discussed the link between patients’ use of fighting metaphors and the optimism they seemed to generate. The same link can be seen in many places in Glaser’s book: Sooner or later, someone is going to survive AIDS and there’s no reason why it can’t be us, if we think positively, stay strong, and keep fighting. (p72) I was too much of a fighter and Ariel had just as much spunk. We would show them we could beat it [AIDS] (p89) I would fight back from the toxins of AZT and not let this virus hold me hostage (p289) This appears to be taking the fact from the source domain that ‘If the fight is going on there is a chance of winning’ and applying it to illness. Glaser writes ..as long as there was hope, we would keep fighting. (p134) But perhaps it is the other way round - as long as people keep fighting they focus on winning and deny the possibility of losing, and that is where the hope comes from. Optimism goes hand in hand with denial, and Glaser fits denial into the metaphor of fighting by mapping it onto the optional elements of an ally and armour: Denial can be a powerful ally, and is part of the armour we rely on when we are in an extreme situation. (p280) It seems that there is a relationship between this positive attitude towards denial and the careful selection of only positive facts from the source domain of fighting. However, the result of using this form of metaphorical thinking seems to be a reasoning pattern where recovery is expected, and the possibility of death is ignored: I still believed that once we diagnosed Ari’s illness and treated it, everything would turn out fine. (p44) The thought of her not getting better never entered our minds. (p43) This comes from the immediacy of a fight, the fact that ‘In a fight, to stand the best chance of winning, everything must be focused on winning’. Naturally, then, when Ariel died, Glaser was not prepared for it: Despite the fact that Ari had been very sick for months, I never believed she was going to die. I could not imagine it and was totally unprepared for it.(p114) I wasn’t ready for her death. (p159) She was never supposed to die. (p160) Even though Ariel was in a terminal condition, it looks like Glaser was using the fighting metaphor to raise her spirits and avoid having to think about the horror of her daughter’s death. This link, between fighting and a reasoning pattern which leads to denial, can be clearly seen in the following quote: I fight to make life the way I want it to be, and at times, that makes me a difficult person to be around. It is because of this, I think, that I never believed that Ari was going to die. (p156) Fact 4: The loser of a fight is a failure When Ariel died, the metaphor of fighting stopped being useful. Instead it seems to have lead to feelings of guilt: Part of me felt it was my fault that Ari died. Even though I knew it was a virus and we fought it as best as we could for as long as we could, part of me still felt like a failure because my love, courage, and determination had not been enough to keep my daughter alive. (p170) This self blame seems to be another consequence of the fighting metaphor. Drawing a fact such as ‘winning a fight is succeeding, losing a fight is failing’ from the source domain seems to lead to feelings of failure if the fight is lost. In the study of cancer patients mentioned above (Stibbe 1997), the fighting metaphor seemed to stop being useful at the point when patients discovered that their disease was terminal. Until that point, the metaphor was helpful in encouraging patients do the best they could to eliminate the cancer. But with AIDS, the situation is different. There is no turning point like this. There is the point where HIV turns into full blown AIDS, and that is where the fighting might begin, but it seems there is no real chance of ‘winning’, if winning is defined as returning to the way things were before the illness. Looking at it this way, with no current cure for AIDS, there seem to be great disadvantages to dealing with AIDS as a fight. But the fight for Ariel’s life was not just against AIDS, but against time. With time came the possibility that a cure might be found: If I give up today and they find a cure for AIDS tomorrow, that would be tragic. I have to fight this war against time with every ounce of strength I have. (p66) ...living with AIDS is living with a time bomb. (307) With Ariel, it felt like the hourglass was running out. Deep in my bones I believed there was a way to keep my daughter alive. (p99) This helps to explain the optimism in the face of what is at present an incurable disease. Certainly, Glaser believed that ‘there are always survivors’. What was important for me at that time was for someone to offer me the option of survival...There are always survivors. (p64) But aside from the small hope of a miracle or cure, a lot was accomplished by Glaser’s fighting spirit. Metaphors have advantages and disadvantages. While it may not have saved her daughter’s life in the end, the fight was not just against AIDS, it was also against the discomfort of hospital: We fought back against being at UCLA [hospital] by making Ari’s hospital room a vibrant and colourful place. We wanted it to feel like a home...There were flowers and balloons, quilts and pillows, toys and stuffed animals (especially her grey bunny) from home. (p101) Later, Glaser fought the drug companies to get intravenous AZT for her daughter before it was officially released. This improved Ariel’s quality of life immensely. And after Ariel’s death, Glaser’s continuing fight against AIDS led her to raise millions of dollars for paediatric AIDS research. Comparing Glaser’s metaphors with those of Monette and Doty Hawkins, analysing the ‘military myths’ in Monette’s pathography ‘Borrowed time’, found a very similar pattern to that of Elisabeth Glaser’s pathography: fighting metaphors, optimism, and unpreparedness for death. There are certain similarities between the two books: they were written within 3 years of each other, both by middle class Americans who, while infected with HIV themselves, were caring for a sick family member. The main difference is that in Monette’s case it was his partner, Roger who was sick. Hawkins (1993:73) notes the link between ‘an aggressive search for a cure’ and ‘an attitude of total denial toward death’. Indeed, it seems that it is specifically the curing illness is a fight metaphor which leads to denial in Monette’s case: The reason everything was going to be all right was really very simple: We would fight this thing like demons. (p8) We never talked about dying because we were fighting so hard to stay alive...(p75) There is a difference between Monette and Glaser’s use of the fighting metaphor however. While Glaser systematically draws entailments from the source domain of fighting which emphasise the strength of the fighter, and the possibility of winning that fighting creates, Monette also draws some negative facts from the domain of fighting: ‘Then someone you know goes into the hospital, and suddenly you are at high noon in full battle gear. They have neglected to tell you that you will be issued no weapons of any sort...You fight tough, you fight dirty, but you cannot fight dirtier than it.’ (p2) Negative facts such as ‘a fight is frightening for the more defenceless opponent’, and ‘the weaker person might well lose a fight’ are always under the surface of Monette’s writing: Yes, we’d decided to fight. No the despair wasn’t gone. The two emotions jockeyed in our hearts...Give us then the bravado of days when we swore we would beat it, for underneath we were scared as ever, and always pleading silently Don’t let it come again. (p104) Fighting compared to war Another difference between the two metaphorical constructions is that while Glaser almost exclusively used metaphors of fighting, Monette mixes the metaphor of fighting with that of warfare, and refers to ‘the war’ throughout his book. Glaser also talks about war, but this is almost completely confined to her family’s war against the media. The difference between the source domains of a fight and a war is that a war is much more general, with far more people involved, and extended in time rather than immediate and all engrossing. While a war is, in general, extremely unpleasant, Monette does not draw only unpleasant facts from the domain of war. The main fact that he draws out is that ‘in a war people on the same side feel a sense of bonding’, and he applies it to his situation: But if I have any sense of how we survived it so long it comes down to an equal measure: an unwavering goal to beat it, and a group of two for an army.... “The pals”, as Roger used to call us, nudging me shoulder to shoulder. 101 Checking in with Bruce and Ceaser was my way of assuring myself there would be no break in the line, for they were my platoon. (p195) If by that time I had come to a point where I felt most comfortable talking with those in the war, it proved a natural thing to include Mrs Knecht. (Monette p170) The reason why the source domain of war is used to a much greater extent in Monette’s work than in Glaser’s may be to do with the difference in their situations. As a heterosexual woman, Glaser was very much fighting on her own. And throughout the book she gives the impression that all the people she met, from other parents to President Reagan himself did not care about AIDS at all. Monette, on the other hand, being part of a gay community where everyone was involved directly or indirectly with AIDS was not fighting on his own. He could therefore talk about a situation where many people were pulling together to deal with AIDS, and used the war metaphor to construct and express this idea. One final point to make is that both Glaser and Monette faced AIDS early on, when very little was known about the illness. The use of the fighting metaphor, and the optimism and denial it involves, may be related to what Monette calls the ‘shadowy non-facts’ about AIDS (p2). Eight years after Monette’s book, another similar pathography, that of Mark Doty, was published. Fighting and War compared to Fading Like Monette, Doty (1996) too was caring for his partner, Wally, who was dying of AIDS. In Doty’s book, in contrast to the earlier ones, fighting metaphors are completely absent, and instead Doty predominantly uses metaphors of his partner ‘gliding down’ (p139) or ‘fading’: “Wally’s progress...seems simple now, a gradual decline, a weakening and fading, a body increasingly unable to co-operate with the dictates of his will: a will that softened, slowly going out of focus, quieting, easing away” (p138) In the absence of the fighting metaphor, we can see that the consequences, those of denial and unpreparedness, also seem to be absent: ‘going straightforwardly toward Wally’s death together, with only the barest denial those last months to keep us sane, had about it a genuineness which we thirst for, and bears with it a kind of satisfaction’ (p64) The reason why Doty does not use fighting metaphors seems to be because of his philosophy that while some things can be changed, other things just go their own course and nothing can be done about them (p152): ‘Don’t we require, finally, a place in our thinking for fortune, or destiny, or whatever we choose to call what will happen to us, how the avalanche will break over us?’(p158). This takes the fact that ‘in an avalanche, there is nothing you can do to stop it’, and applies it to the target domain of illness. And Doty applies the avalanche metaphor directly to his partner’s illness, linking to the general metaphor of descent: ‘Now the years of Wally’s illness seem to me an avalanche but at the time they felt more like a descent so gradual as to often be imperceptible’ (p139). And the consequence of these metaphorical ways of thinking seems to be that Doty was able, at least mentally if not emotionally, to prepare for the death of his partner: I had this long time to look at what was coming...I made the arrangements, found the help, discovered what could allow Wally and me to live as best we could, but what preparation could I make in my heart? (p106) Conclusion The case study above was just a brief look at some of metaphors in pathography but illustrates several points about the study of metaphors and illness. The first point is that choice of entailments is selective. In Glaser’s case, she takes the positive facts of a fight, such as ‘fighters are strong’ and ‘while the fight is going on there is a chance of winning’, and ignores the negative entailments of a fight such as fear and injury. Monette, on the other hand, while drawing on some positive aspects of a fight, brings out negative ones as well. The second point is that by examining a pathography it is possible to get an indication of the effects of particular metaphors and entailments on reasoning. Thus it was possible to see the metaphor of fighting led to unpreparedness for death in the case of both Glaser and Monette, whereas Doty, who used metaphors involving ‘fading’ and ‘an avalanche’ was better prepared. A third point is that consideration of the entailments that people draw from metaphors and their background situation can help explain why people chose particular source domains to structure their experience. Very often the source domains of fighting and warfare are treated by analysts as being the same thing. Hawkins, for example, uses the term ‘military metaphor’ to cover fighting, battling and warfare metaphors. However, the source domain in each case is slightly different, and therefore the facts which can be drawn from the source domain and used in metaphorical reasoning are also different. In the study presented, the difference between Glaser’s use of source domain of fight and Monette’s use of war seemed to be related to their different situations. This paper only makes one small point about the study of metaphors of illness but it is hoped that it is a useful one. The idea proposed is that when examining metaphors of illness it is important to consider exactly which facts from the source domain are being used in metaphorical reasoning, by considering textual evidence, and then trying to understand the effects that the entailments have on the patients. Pathography provides a particularly useful source of data for such analysis. For example, Glaser’s initial use of fighting metaphors and the eventual outcome, her unpreparedness for death, could only be seen in a chronological record such as pathography. It is hoped that through the detailed analysis of the metaphors in pathology it might be possible to learn more about how metaphors influence the experience of people who are ill. I do not see it as the role of the analyst of metaphor to recommend ways of thinking about illness to patients, since every situation and every person is unique. But I do believe that a knowledge of the metaphors and entailments used by people in the past, and a knowledge of the effects that these seemed to have on their lives could help give patients and their relatives a choice in the way they think about illness. References Diekema, Douglas. 1989. Metaphors, Medicine and Morals. Soundings, 72(1):17-24 Doty, Mark. 1996. Heaven’s Coast. New York: Harper Perennial Glaser, Elizabeth. 1991. In the Absence of Angels. London: Arrow Goatley, Andrew. 1997. The Language of Metaphors. London: Routledge Gray, Ross and Brian Doan. 1990. Heroic Self-Healing and Cancer: clinical issues for health professions. Journal of Palliative Care, 6(1):32-41 Hawkins, Anne Hunsaker. 1993. Reconstructing Illness: studies in pathography. Indiana: Purdue University Press Johnson, Mark. 1983. Metaphorical Reasoning. Southern Journal of Philosophy, 21(3):371-389 Johnson, Mark. 1987. The Body in the Mind. Chicago University Press Jones, Anne. 1984. A Commentary on ‘Two Pathographies: a study in illness and literature’. Journal of Medicine and Philosophy, 9:257-259 Kirmayer, Lawrence. 1988. Mind and Body as Metaphors: hidden values in biomedicine. In M. Lock and D. Gordon (eds), Biomedicine Examined, 57-93. Lancaster: Kluwer Academic Publishers Lakoff, George and Mark Johnson. 1980. Metaphors We Live By. University of Chicago Press Lakoff, George and Mark Johnson. 1999. Philosophy in the Flesh. New York: Basic Books Monette, Paul. 1988. Borrowed Time: An AIDS memoir. New York: Avon Books May, William. 1983. The Physician's Covenant: images of the healer in medical ethics. Oxford: Westminster Press Ross, Judith. 1989. The Militarisation of Disease: do we really want a war on AIDS? Soundings, 72(1):39-58 Sontag, Susan. 1979. Illness as Metaphor. London: Allen Lane Sontag, Susan. 1989. AIDS and its Metaphors. Penguin Stein, Howard. 1990. American Medicine as Culture. Oxford: Westview Press Stibbe, Arran. 1997. Fighting, warfare and the discourse of cancer. South African Journal of Linguistics. 15:2:65-70 PAGE 1