Metaphoric and descriptive terminology in dermoscopy: Lessons from the cognitive sciences.

Abstract

Metaphoric or analogical terminology is common in clinical dermatology, dermoscopy and dermatopathology. Metaphoric language in dermatology has been criticized for a perceived lack of clear definition and specificity, and non-metaphoric (descriptive) terms and diagnostic algorithms have attempted to be constructed. Metaphors are pervasive in human language and appear to be deeply rooted in our conceptual frameworks. The utility of metaphors in dermoscopy is discussed, with particular reference to research in the cognitive sciences. Introduction: Metaphoric language in dermatology, dermoscopy and dermatopathology Metaphor is a complex subject in language and cognitive science. It is a linguistic and conceptual tool commonly used in science and the arts and has been defined as “understanding and experiencing one kind of thing in terms of another” [1]. Metaphors are a special form of analogy or association, and aim to help the learner comprehend and communicate new or unfamiliar (“target”) information based on known or familiar (“source”) knowledge. Lakoff and Johnson propose that our abstract thoughts are largely metaphoric, and that metaphoric language is secondary to this [1]. In their view “metaphoric thought is unavoidable, ubiquitous, and mostly unconscious,” having developed automatically in childhood as we learn to function in our everyday world [1]. Consequently, they regard metaphor as a natural and unavoidable aspect of human language. Metaphors are widely used in the dermatology lexicon, developed to aid recognition and description of clinical, dermoscopic, and dermatopathologic criteria. Examples include the prefix “lichen” in lichen planus, “bamboo” hair, “guttate” psoriasis, “arborizing” telangiectasias, “saw tooth” pattern, and so on. Besides explicit metaphoric terminology, covert metaphoric concepts are also common. The “disease as an enemy” metaphor is one example, wherein the dermatologist uses various diagnostic or therapeutic “armamentaria” to “fight” or “combat” the disorder [2]. However, metaphors have received criticism in the dermatologic literature in recent years. Notably, Ackerman says [3]: “. . . cliches are ubiquitous in dermatology and pathology in general and in dermatopathology in particular, the realm of inflammatory skin diseases being no exception. . . . Images like ‘corps ronds and grains’ . . . , ‘dilapidated brick wall’ . . . , ‘tombstone pattern’ . . . , ‘festooning’ . . . , ‘flame figures’ . . . , ‘ground-glass cytoplasm’ . . . , and ‘saw tooth pattern’ . . . may be picturesque, but none of them lend themselves to definition meaningfully by those who mouth them . . . Moreover, not a single one of those whimsical mental pictures has specificity.” [3] In sum, Ackerman regards these metaphors as lacking clear definition and specificity. Similarly, Kittler criticizes metaphors in traditional dermoscopy [4]: “The images invoked by metaphoric terms and opaque expressions result inevitably in failure to conjure the very same construct in the brain of any two individuals. Examples: ‘Leaf-like areas,’ ‘fingerprint-like structures,’ ‘fat fingers,’ ‘radial streaming,’ ‘moth-eaten border,’ ‘blue gray veil,’ and ‘honeycomb-like pattern.’ Those images impede repeatable diagnosis by dermatoscopy and prevent rational communication between dermatoscopists.” Moreover, Alendar et al [5] write, under the heading “No need for metaphoric language,” that “The current language of dermatoscopy consists mainly of metaphoric terms that are badly defined. This language is extremely confusing and discourages students to learn the technique profoundly.” The above viewpoints present metaphors as being non-scientific, lacking clear definition and specificity. Metaphor is thus regarded as a hindrance to understanding and communication in dermatology, dermatopathology and dermoscopy.