Are prostheses a blessing or a curse? Do they improve quality of life or dehumanize those who wear them? Annika Wellmann-Stühring explains how prostheses have developed over the past few centuries and what social significance they have.
What is a protheses?
Prostheses are common everyday companions; hardly anyone evades them. They sit as spectacles on the bridges of noses or swim as contact lenses on corneas. As hearing aids, they cling to the backs or insides of ears. As dentures, they guarantee hassle-free eating, clear pronunciation, and a lovely smile. And in the form of pacemakers, they provide the beat for a steady cardiac rhythm. Life without prostheses is unimaginable.
The word prosthesis stems from the Greek for “addition, attachment.” Prostheses are replacements for body parts and organs made from exogenous materials. They are intended to help make life as problem-free as possible after a physical loss—whether through illness, accident, or war injury. In the words of medical historian Thomas Schnalke, they render “substitute services to the body, on the body, and in the body.”1
Prostheses are highly differentiated and serve various purposes. Arm and leg prostheses restore lost functions and allow experienced users to walk or grip again. Hearing and seeing aids invigorate dwindling senses. Epitheses modeled on eyes, ears, or nose provide cosmetic compensation. Unlike prostheses, however, they cannot replicate the functions of these body parts—seeing, hearing, and smelling. Implants and endoprostheses are also prostheses, ones that are not affixed to the body exterior, but rather disappear inside it. Lens implants, pacemakers, artificial heart valves, joints, blood vessels, and cranial plates along with breast, calf, and buttock implants are anchored inside the body and often perform their duties there for a lifetime.2
1 Thomas Schnalke, “Das Fremde im Dienst des Eigenen. Die Prothese,” in Fremdkörper – Fremde Körper. Von unvermeidlichen Kontakten und widerstreitenden Gefühlen, eds. Annemarie Hürlimann, Martin Roth, and Klaus Vogel (Ostfildern-Ruit 1999), p. 133.
Dentures have been around since the 18th century. Back then, they were made of porcelain and were more aesthetic than functional.
Since time immemorial, humans have tried to replace missing limbs and compensate for impaired body function with prostheses. The development of prosthetic care depended on the discovery of suitable materials, the evolution of construction knowledge, and the dissemination of medical innovations. But where could prostheses attach to the body? Should they provide aesthetic or functional recovery? And who would profit from the technology? Contemporaries of different eras answered these questions differently.
According to Schnalke, a “sober understanding of the body” informed prosthetics from the outset.3 The body was dealt with objectively. Those who had lost a body part or its function should be able to replace it with an aid. The primary concern was that those affected become as little a burden as possible on society, continue performing the tasks assigned to them, and be able to feed themselves. In the Middle Ages, those suffering from leprosy, who were often dependent on alms, moved on wooden weights. Those who had suffered an amputation strapped a wooden leg or hook to their remaining limb in order to find work. Monks compensated for poor eyesight by placing magnifying reading stones on the texts they wanted to study. In the late 13th century, the polished and mounted glass then found its place on the face.
In the 16th and 17th centuries, wars and the anatomists’ new views into the body, which generated insight into functional biomechanical relationships, provided the impulse for an upsurge in prosthetics. Designers devised intricate apparatuses. Only the wealthy, however, could afford these aids, whose production required a great deal of technical skill. The prosthetic iron hand of Franconian Imperial Knight Götz von Berlichingen (1480–1562) is a well-known example.4
It wasn’t until the 19th century that prostheses became more widely disseminated, preceded by a series of technical innovations. Dentists, for example, discovered new techniques for reliably fastening dentures and found new materials that could resist the aggressive oral environment and chewing forces, did not trigger tissue reaction, and satisfied aesthetic needs.5 Starting at the turn of the 20th century, ever smaller electronic hearing aids based on evolving telephone technology began to replace the large dark ear trumpet, which made hearing loss all too visible.6
Doctors and craftspeople constantly contrived new equipment of wood, leather, brass, copper, or animal hide to replace limbs, integrating anatomical and biomechanical knowledge in their designs. Thus prosthetic ankle joints with feet that could be moved in any direction emerged back in the early 19th century along with hinge-joint knees that provided a high degree of stability and thus became models for a number of subsequent prosthetic constructions.7
Prosthetic development benefitted from the idea, which had been spreading since the Enlightenment, that the body is a machine whose parts are replaceable. Technical innovations also gained acceptance because medical improvements like anesthesia made surgical interventions bearable and better hygienic devices improved the chances of surviving complicated surgeries. And starting in the late 19th century, at least in Germany, statutory accident insurance made aids accessible to people with low incomes.8
Prosthetics gained particular relevance during and after World War I. Attrition warfare produced victims on all sides in previously unknown numbers. Nine and a half million soldiers died, 20 million were seriously wounded, and eight million returned to their homelands as invalids.9 On the German side alone, some 70,000 soldiers suffered the loss of a limb. To guarantee care for the large number of returning injured soldiers, reintegration in the labor market had to proceed quickly. Modern prostheses were to make this possible.10
Prosthetic technology evolved into a mass technology. To guarantee comprehensive fittings for artificial limbs, doctors and engineers sought to standardize the individual pieces. These were pre-produced in series by the emerging prosthetics industry, which included companies like Orthopädische Industrie GmbH (from which Otto Bock HealthCare GmbH later emerged, still active today as market leader in many areas).11 Particular attention was paid to the so-called work arms, which sought not to mimic the appearance of hands, but to restore their function. Here, the remaining limb was directly coupled with a tool: rather than ending in a hand, the artificial limb ended in a hammer, a ring, or a claw. In the construction of prostheses, the “form follows function” formula prevailed.12
Two World Wars within 30 years meant that there were more disabled veterans than ever before living in virtually all countries involved. They were joined by a large number of people who had suffered physical losses due to workplace accidents or disease. Experts exchanged knowledge to promote the widespread provision of prostheses. During the postwar period, American experts traveled to Europe, where since World War I, prosthetic technologies were reputed to be particularly sophisticated. In turn, German experts discovered new materials and technologies on study trips to Anglo-Saxon countries.13
Starting in the late 1950s, prosthetic technology again experienced bursts of innovation. Electronics enabled sophisticated control systems. Prostheses like the myoelectric arm were developed, which operates by using the muscular potential in the remaining limb. Electrodes in the shaft receive the muscular impulses, amplify them, then forward them to an electric motor, which opens, closes, or turns the prosthetic hand. Fitted with a cosmetic casing, these prostheses also conceal the amputation.14
When plastics triumphed in the 1960s, all other materials became increasingly irrelevant. Their accuracy of fit guaranteed close contact between aid and body, and their specific qualities also allowed for the tapping of new areas for development. Waterproof artificial legs, for example, made beach and pool trips possible. In the 1980s, the introduction of carbon enabled the production of the sprinting and jumping prosthetics with which competitive athletes like Aimee Mullins, Oscar Pistorius, and Markus Rehm have been causing quite a stir in recent years.15
3 Thomas Schnalke, “Der ersetzbare Mensch. Aus der Geschichte des Körpers und seiner Prothesen,” in Leben mit Ersatzteilen, eds. Sabine Gerber-Hirt et al., (Munich, 2004), p. 12.
The first epitheses meant to mimic eyes, ears, and nose were made of porcelain. Not until the 20th century did manufacturers begin to produce them using PVC and silicone.
4 Ibid, pp. 12–15.
5 Walter Rathjen, “Zahn und Kiefer,” in Leben mit Ersatzteilen, eds. Sabine Gerber-Hirt et al. (Munich, 2004), pp. 44–58.
6 Reiner Hüls, Die Geschichte der Hörakustik. 2000 Jahre Hören und Hörhilfen (Heidelberg, 1999), pp. 126–138.
7 Sabine Gerber-Hirt, “Gliedmaßen und Gelenke,” in Leben mit Ersatzteilen, eds. Sabine Gerber-Hirt et al. (Munich, 2004), p. 86.
8 Elsbeth Bösl, Politiken der Normalisierung. Zur Geschichte der Behindertenpolitik in der Bundesrepublik Deutschland (Bielefeld, 2009), p. 290.
9 Deborah Cohen, “Kriegsopfer,” in Der Tod als Maschinist. Der industrialisierte Krieg 1914-1918, eds. Rolf Spilker and Bernd Ulrich (Bramsche, 1998), p. 217.
10 Sabine Kienitz, Beschädigte Helden. Kriegsinvalidität und Köperbilder 1914-1923 (Paderborn et al., 2008), p. 156.
11 Peter Berz and Matthew Price, “Ersatzglieder,” in Der [im-]perfekte Mensch. Metamorphosen von Normalität und Abweichung, eds. Petra Lutz et al. (Cologne, 2003), pp. 143–161.
12 Heather R. Perry, “Re-Arming the Disabled Veteran. Artificially Rebuilding State and Society in World War One Germany,” in Artificial Parts, Practical Lives. Modern Histories of Prosthetics, eds. Katherine Ott et al. (New York et al., 2003), pp. 75–101.
13 Elsbeth Bösl, Politiken der Normalisierung. Zur Geschichte der Behindertenpolitik in der Bundesrepublik Deutschland (Bielefeld 2009), p. 299 and C. W. Radcliffe, “Above-knee Prosthetics,” in Prosthetics and Orthotics International (1977), pp. 146–160.
14 Sabine Gerber-Hirt, “Gliedmaßen und Gelenke,” in Leben mit Ersatzteilen, eds. Sabine Gerber-Hirt et al. (Munich, 2004), p. 99.
15 Eva Schneider, “Geparden-Beine aus Karbon,” www.anthropofakte.de/node/298 (accessed July 30, 2015).
The second half of the 20th century witnessed another revolution in prosthetics: the technology went below the skin. Materials like silicone and titanium, highly differentiated technologies, and progressive miniaturization enabled the insertion of prostheses inside the body. Meanwhile, improved surgical procedures and hygienic standards decreased the risk of complication. What doctors had been trying since the late 19th century—usually without success and often with disastrous consequences—was now finally possible: pacemakers, artificial lenses, joints, blood vessels, breast implants, and auditory prostheses were placed inside the body, where they effectively performed their services.16
Due to demographic change, today mostly older people use prostheses. But many young people also need aids as the result of diseases like diabetes and cancer or injuries caused by accidents. The need is particularly acute in war and crisis zones, where serious injuries are caused primarily by landmines. In those areas, humanitarian organizations are currently striving to provide affordable artificial limbs whose technical simplicity guarantees easy maintenance.17
16 Sabine Gerber-Hirt et al., eds., Leben mit Ersatzteilen (Munich, 2004).
17 Sabine Gerber-Hirt, “Gliedmaßen und Gelenke,” in Leben mit Ersatzteilen, eds. Sabine Gerber-Hirt et al. (Munich, 2004), p. 97.
According to sociologist Werner Schneider, today’s discussions about prostheses swing “between the poles of a culturally critical technophobia and an auspicious technology apology.” While some fear dehumanization through technology, others celebrate the improvements in quality of life associated with prostheses.18 Blessing or curse, prostheses are by now part of everyday life. They are often greatly beneficial. And they reveal what is important to us.
The purpose of prostheses has always been to enable self-reliant living and prevent dependence. Special emphasis has thus always been placed on the recovery of labor power; functionality is required. The majority of prostheses, however, are also meant to reconstruct or preserve physical appearances. Contact lenses lie invisibly on the eye; hearing aids have become smaller and smaller. Facial epitheses do nothing but conceal defects, liberating those who have them from psychological distress and social isolation. With epitheses, they dare go out in public again. The aim is to hide injuries, which are considered a stigma.
There is also a movement in the opposite direction. Those who opt for functional, high-tech prostheses with a technical look and feel, renounce cosmetic casing, and present openly elaborate mechanisms send a signal to the world that they’re enjoying life to the fullest. Take American biophysicist and mountain climber Hugh Herr, for example. In 1982, he lost both lower legs in a climbing accident, then became, with his ultramodern prostheses, the figurehead of a “Bionic Age” in which humans and technology are productively fused.
At the turn of the new millennium, a further demand asserted itself on a broad scale in the technical modulation of bodies. Instead of merely conforming to the idea of a “normal” body and rehabilitating disabled bodies as best as possible, bodies are now meant to be technically enhanced.19 In this view, we are all fundamentally in need of improvement.
According to Karin Harrasser, the requirement to optimize oneself with the help of technology buttresses current “neoliberal techno-biopolitics,”20 which seek to improve the well-being of individuals and populations through technology. The dark side of techno-biopolitics includes, for example, surveillance technologies that hardly anyone can escape. Self-improvement through technology, on the other hand, is pursued on an apparently voluntary basis and is lucrative because it is designed to boost individual potential.
The best examples of that are breast and buttock implants, which serve an aesthetic purpose and are meant to provide more beauty and attractiveness. The implant surgeries, which patients must finance themselves, comply with personal preferences and are associated with a desire for autonomy. Above all, however, they’re about adapting one’s own appearance to prevailing physical ideals that promise a sense of belonging, success, economic advancement, and social recognition.21
Whether they aim to compensate or improve, prostheses enable participation. In societies where productivity is a central value, this participation usually meant professional performance. But as part of the effort toward “inclusion,” leisure activities and socializing are increasingly moving to the foreground: prostheses must now also enable people to share experiences with family and friends, play sports, and pursue hobbies.
At the same time, the idea that injury and disability are not, after all, physical deficiencies to be negotiated using only technical means has been gaining ground for several years. What disabilities are and how people live with them depends on social context: on images of self and other, on attitudes held among the populace, and on the design of the environment. Prostheses designed to correct alleged defects are thus no longer considered cure-alls. They are, however, still in demand, and their development remains an important task of design. Still, it’s important to accept people with disabilities as they are or want to be and to assure them a chance at social participation by creating barrier-free environments.22
In the 13th century, monks mounted polished glass on their noses to compensate for poor eyesight—a forerunner of today’s eyeglasses.
18 Werner Schneider, “Der Prothesen-Körper als gesellschaftliches Grenzproblem,” in Markus Schroer, ed., Soziologie des Körpers (Frankfurt am Main, 2012), p. 371.
The first prostheses with ankle and knee hinge joints appeared in the early 19th century. From then on, prosthetic legs were no longer stiff.
19 Ibid, 383.
20 Karin Harrasser, Körper 2.0. Über die technischer Erweiterbarkeit des Menschen (Bielefeld, 2013), p. 12.
The first cardiac pacemakers were designed in the 1950s, although it was another decade before they could be implanted.
21 Paula-Irene Villa, “Wider die Rede vom Äußerlichen,” in Paula-Irene Villa, ed., Schön normal. Manipulationen am Körper als Technologien des Selbst (Bielefeld, 2008), pp. 7–18.
22 Elsbeth Bösl, Politiken der Normalisierung. Zur Geschichte der Behindertenpolitik in der Bundesrepublik Deutschland (Bielefeld, 2009).