New Worlds: Prostheses and Assistive Devices

(This post is part of my Patreon-supported New Worlds series.)

Given that the last essay discussed medical interventions like amputation, it seems like a suitable time to take a look at the devices we’ve developed to help people deal with disabilities of many kinds — and what kinds of improvements could still be made.

Defining my terms first: a prosthesis replaces a missing body part, while an assistive device is anything meant to help the user function more effectively, specifically in situations of disability. (You could make a semantic argument that, say, my phone is an assistive device for helping me remember appointments, but that’s not the sense I’m looking at here.) Overall the aim of a prosthesis tends to be to restore function in the missing part, but that category also includes things like artificial eyes, which — so far! — are not able to provide any visual input. They’re only there to normalize the wearer’s appearance.

Which, right there, is a whole can of worms on the disability front. Modern materials engineering has poured huge amounts of effort into making prostheses lighter and more comfortable to wear for long periods of time; we are long past the limitations of, say, a wooden leg. But there can still be pressure for an individual to wear a prosthesis for other people’s comfort, even if that’s not so great for them, so that nobody has to confront the sight of an amputated limb. Although much of the attention here will be on function, that’s hardly the only aspect in play: how much expectation is there of “normal appearance,” versus acceptance of differences?

But the main idea behind a prosthesis is that it should restore at least some functionality. The three main categories for limb prostheses are passive, body-powered, and externally powered, of which the former is the oldest type by thousands of years: we’ve got the foot of a New Kingdom Egyptian mummy from around 1000 BCE that sports a wooden toe, whose wear patterns show the user definitely walked on it. (Our absolute oldest archaeological evidence of a prosthesis is a cosmetic false eye in Iran; that one predates the toe by another two thousand years.) You can find examples of these in mythology, too! After Demeter failed to notice that Tantalus had served up his son to feed the gods and noshed on his shoulder, Hephaestus made him a replacement out of ivory.

Passive prostheses were historically made out of wood or metal, with various arrangements of straps and so forth to hold them on. As you can imagine, this means they were very heavy compared to their modern counterparts. And while some of them were (and are) adjustable — for example, a hand that can be locked in an open or closed position — the functionality they provide is limited. Someone with a wooden foot or leg can walk, but it takes much more energy than usual; someone with a metal hand can pin objects in place, or even swap the hand out for specialized prostheses like a pen or a knife, but they won’t have the full dexterity of a healthy hand. (And yes, sometimes a hand prosthesis takes the form of a hook. J.M. Barrie didn’t make that up.)

With modern materials, these limitations can be greatly improved. Back in 2008, the Olympics wrestled with a dispute over Oscar Pistorius, a runner who used “blade”-style prosthetics in place of his amputated feet; although officials ultimately ruled that the reduction in energy usage granted by the prosthetics did not outweigh his overall disadvantages, it conjured the image of a future where prosthetics may become more effective than what nature granted us. We aren’t there yet, but the notion isn’t an absurd one.

Development isn’t only about improving passive function, though. Especially for hands, there’s a lot to be gained from making fingers and wrists that can respond to the wearer, providing a greater range of capability. Body-powered prostheses rely on harnesses and cables to achieve this effect, while externally powered ones use electrodes to read impulses from nearby muscles and spark a response in the prosthesis. I’ve definitely seen science fictional extrapolations of this, where an artificial limb is controlled by the brain in essentially the same fashion as a biological one: all I have to do is decide to pick up my water glass, and my hand will perform that task. I’ve yet to see a magical equivalent, though — if anybody has examples, please mention them in the comments!

Assistive devices occupy a much broader range, because they encompass anything that can help a person carry out tasks more easily and effectively. This includes everything from a stick to help a blind person detect obstacles or Braille to help them read, to ear trumpets (a few hundred years old) or hearing aids (recent) to amplify sound for someone hard of hearing, to the glasses and contact lenses many of us wear, to OXO’s Good Grips line of kitchen utensils — the founder originally created those to help his wife, whose arthritic hands made ordinary utensils difficult to use without pain.

Mobility devices are a huge category here, because mobility problems are something a huge percentage of the population faces sooner or later. The use of a staff or a cane for balance and support in walking is truly ancient, to the point where such a thing is a common symbol for old age. Wheelchairs have a more complex history; the earliest use of wheeled seats to transport someone seems to be from China around the second century BCE, though truly purpose-built devices came about seven or eight hundred years later. (Europe caught up to this idea about a thousand years after China.) The older forms of those, however, required someone else to roll you around. The issue of weight again rears its head: the first self-propelled wheelchair was essentially a hand bike, relying on gearing to create enough force to move the mass of the chair plus its occupant. The basic design that’s common now wasn’t invented until the 1930s, at which point you finally had lightweight, foldable chairs that allowed users to control their own movements.

Which is the point I want to end on. There are multiple reasons for the backlash against “cure narratives” for disability in fiction, but one of them is that it points people’s attention toward a goal that may or may not ever be feasible, and away from the changes that can improve the lives of people with disabilities right now. Improvements in prostheses, creative development of assistive devices, and changes in the physical and social environment (like the U.S. Americans with Disabilities Act, which mandates things like wheelchair-accessible entrances) make an enormous difference in people’s ability to live full and satisfying lives. Speculative fiction often gives us magic or futuristic technology that waves these problems out of existence; it devotes much less thought to how those elements could be used to make incremental improvements instead.

But I owe my kitchen full of comfortable gadgets to Betsy Farber’s arthritic hands. What else might we create, if speculative fiction gave us the idea?

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About Marie Brennan

Marie Brennan is a former anthropologist and folklorist who shamelessly pillages her academic fields for inspiration. She recently misapplied her professors' hard work to the short novel Driftwood and Turning Darkness Into Light, a sequel to the Hugo Award-nominated Victorian adventure series The Memoirs of Lady Trent. She is the author of several other series, over sixty short stories, and the New Worlds series of worldbuilding guides; as half of M.A. Carrick, she has written The Mask of Mirrors, first in the Rook and Rose trilogy. For more information, visit swantower.com, Twitter @swan_tower, or her Patreon.

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New Worlds: Prostheses and Assistive Devices — 17 Comments

  1. Often, the assistive device works best in combination with an adjustment to the built environment/infrastructure and the way *everybody* can move or behave. I think that is an important part of thinking about incorporating this in your fiction.

    If there is some special reason why a whole lot of people have a specific disability sometimes you see these kinds of adjustments, e.g. in a village where 1 in 4 people are born deaf everybody might learn sign language. Wouldn’t it be great if all primary schools taught sign language as a second language routinely to everyone?

    What would it mean for a society if all buildings had ramps and elevators instead of or in addition to steps, if all sidewalks had guidance stripes for blind walkers using a stick, and kerb cuts or ramps wherever anyone on wheels might want to cross, and safe signalised crossings (with an audible as well as visual signal) on all busy streets.
    Handicapped-access toilets in all public buildings, or all houses being built handicapped-friendly?

    Sometimes improvements made towards safety or equality for one group (e.g. separating cyclists from cars and pedestrians) can bring benefits to whole swathes of society not considered in the first case. Once that effect is noticed, it can be consciously expanded upon (e.g. by building cycle paths wide enough that trikes or cargo bikes can pass one another).
    Consider the way mobility, independence and fitness is improved for lots of people with disabilities by having safe cycling/micromobility options throughout the whole network, that can be safely used to go anywhere by handcyclists, people on mobility scooters, trikes for people with balance issues, people with limited vision or other handicaps like diminished reaction times that can’t drive cars, children (over 8-10 years old) moving about independently, sociable (side-by-side) tandems for blind people, etcetera: https://bicycledutch.wordpress.com/2018/07/03/inclusive-cycling-on-tricycles/ (and the linked earlier short film of random people on mobility scooters)

    I’d really like to see more of that kind of built-in accomodation making things easier for everyone in fiction, without it being made a big fuss over: not turning it into “message” fiction, but just as a normal accepted part of everyday life, as our Dutch cycle paths are here.

    It only dawned on me how special they are, how much taken-for-granted freedom they give to nearly everybody, when I saw what a big fuss is being made over them by some English-language transportation, infrastructure and city-building people. Just for counting to 3 based on physics, weight and speed when designing infrastructure (1 pedestrians, 2 cyclists & other micromobility options, 3 heavy motorised vehicles capable of higher speeds and thus capable of doing a lot of damage to vulnerable human bodies) – most countries apparently only count to 2 (1 traffic, 2 pedestrians, at the most).
    From what I’ve read, for many foreign visitors with an eye for city-building or infrastructure this idea is eye-opening, and leads to many ideas on improving their own areas. Others don’t know why, they just feel safe walking around or renting a bike, savouring the birdsong and ‘continental atmosphere’, never realising it’s the separation from motorvehicles that makes it possible.

    What is “fit for purpose” can depend on a weighing of different influences: in an area prone to flooding high kerbs and doorsteps can be very useful or even necessary, but they create obstacles for anyone on wheels (or with a baby carriage etc.). A solution might be to make them all with sloping sides, like ramps, but that takes more space. A balancing that doesn’t automatically take the cheapest option, but that prioritises equal access for everyone would say something important about that society.

    I wish a lot more fiction could help show and create such inclusive environments, not just by including people with disabilities, but by not making a fuss about it and just showing how an environment that is built to suit all people means people who are differently abled can function just as well.

    • I’d really like to see more of that kind of built-in accomodation making things easier for everyone in fiction, without it being made a big fuss over: not turning it into “message” fiction, but just as a normal accepted part of everyday life

      You’re absolutely right about the ways the world can be engineered for greater accessibility to all. From a writing standpoint, the challenge is that “a normal accepted part of everyday life” is the kind of thing you mostly don’t describe, precisely because it’s ubiquitous and the characters take it for granted — and the act of describing it often makes it feel like it’s being called out in order to send a message. Finding the balance point for that can be tricky.

    • Ubiquitous kerb cuts and accessible intersection signals just cost modest amounts of money (apart from kerb flood risk I guess), and are pretty common in some cities. The cuts help sidewalk bicyclists, too; in Cambridge MA I noticed a trend of re-cutting sidewalks, and also my frustration when I hit a sidewalk that wasn’t cut yet. (Biking on the sidewalk is legal in Massachusetts.)

      ‘Handicapping’ all buildings has more significant trade-offs though, ruling out many traditional or creatively space-using buildings, especially narrow ones. No room for a ramp or elevator, and/or *significantly* adding to the cost of the building, and thus of housing.

      • True for retrofitting in real life, but not taking it into account from the start does limit the lives of handicapped people. If their own home is accessible, but the homes (or just the toilets) of all their friends aren’t, that puts some rather severe limits on their options for socialising, and for where they can choose to live.

        Ditto for businesses, shops, cafés, restaurants, and services. Living in an old town center might be ideal for being in walking/wheelchair/handcycle range of most of the shops and services you need (so you’re not dependent on costly and unreliable taxi services*); but if historical preservation regulations or a lack of funds mean groundfloor access and facilities in those shops and offices cannot be adapted to be accessible, that negates all that convenience.

        * A blind friend in Houston, living in an appartment complex, complains that almost 3 out of 4 times he tries to schedule an appointment with a taxi or Uber the driver doesn’t show up, saying he can’t find the appartment, or there isn’t a convenient parking spot. Even waiting at the kerb for half an hour or more, in all weathers, doesn’t guarantee he’ll be picked up. That means constant rescheduling of vet’s and doctor’s appointments, government appointments to try to get a disability allowance (he’s been trying for years, but Texas intentionally makes it so difficult he’s not succeeded yet) and such.
        Because there’s hardly any sidewalk and no safe crossroads he is effectively housebound unless his one remaining old friendly acquaintance picks him up with his car – but the friend gets ill or forgets fairly often. So he orders all his shopping online, but even with the delivery instructions stated clearly half gets delivered to the management office on the wrong side of a 4-lane highway with no safe crossing. Then the manager often refuses to get someone to take it across (“we can’t start doing that, everybody would want us to run their errands”), but sends it back to the store instead as the blind man can’t cross the busy highway without a signalised crossing, to come and get it himself.
        The awfulness of this dependency on the erratic kindness or persistence of strangers (delivery people and taxi drivers, and sometimes the manager’s assistant), and being effectively forced to endure near house arrest because the environment does not allow one to move about independently hits me hard.
        Especially when contrasted with the blind man who lives around the corner from my parents, walking independently with his guide dog, going to the local shops or the nearby bus stop, taking the bus daily to go to work, or just taking a nice walk in good weather, enjoying a chat with people he meets. With the ubiquitous safe sidewalks, low (& slow) traffic residential neighborhoods and local shopping street, good bus and train services, that man can live a normal and productive life, going almost anywhere he wants independently.

        Creating that environment is done by policy choices. Those choices have consequences beyond the financial.

  2. One is reminded of Dag in Lois McMaster Bujold’s Sharing Knife quartet, who lost a hand a while back and has a whole set of artificial replacements (hook, fork, hand-to-grip-a-bow…)

  3. As with lots of definitions, sometimes the dividing line can be blurry. For instance, the man who is missing a leg but uses a cane as a leg replacement. Contact lenses are almost replacing a lens. When hearing aids and insulin pumps and phones and computers are implanted the merging will be more complete.

    • Fair point! My pipe dream is getting an ICL, an implantable collamer lens — which pretty much is just a contact lens put inside the eye instead of on top of it.

  4. Pingback: New Worlds: Prostheses and Assistive Devices - Swan Tower

  5. Then there are “assistive devices” that are much less visible, primarily because they’re not for mobility, manipulation, or sensory input. Consider, for example, the colostomy bag and system (dating to early 18th century). Modern colostomy systems are worn under the clothes, and when properly installed “accidents” are less common than for kindergarteners.

  6. “I’ve yet to see a magical equivalent, though”

    Benedict of Amber got a magically functional silver arm to replace his missing one, though he didn’t get to keep it because timey-wimey.

    Dag developed a different form of magical prosthetic. <_<

    I feel like there should be more but can't recall any. Maybe it feels simply to just go straight to magic regeneration.

    • First one that came to mind for me was Peter Pettigrew in Harry Potter and the Goblet of Fire. He received a silver (mist-like?) hand.

  7. I’m sure there are novels where characters have magically had enhancements such as wings, or fixed blindness.

  8. Yes, “It’s a Wonderful Life” and an angel earning its wings.

    How about seven-league boots?

  9. I actually enjoy reading/watching science fiction in which prosthetic replacements are taken for granted — tech advancements being one of the hallmarks of the genre. Marie is right that calling a lot of attention to them might be intrusive in the story. Though in my far-future novels, my hero born on a low-tech planet raises doubts about the wisdom of allowing cyborgs in the “WorldPlan.” I used to agree with her, but now that my various body parts are falling apart, I’m all for cyborg replacements! My husband Thor has peripheral neuropathy, and a strap-on device for his calf gives him a push-off to let him walk/hike almost normally. Not sure if that’s called a prosthetic or assistive device.

  10. Dragonlance Chroinicles series (1980s) had Threros Ironfeld, a one armed smith who gets the Silver Arm of Ergoth, a artifact replacement arm that grants him the power to forge the Dragonlances. The Eberron D&D setting has magic prosthetics.