My New Leg

from Steven Kurzman (2003) Performing Able-Bodiedness: amputees and prosthetics in America. Ph.D. dissertation, University of California, Santa Cruz

While en route to Cook County Hospital one day to drop off a prosthesis for a patient, I asked Cliff what made a good prosthetist. He replied simply, “you do good work.”

I asked, “so, what is good work?”
“Your patient walks,” he answered.
“Okay. So what makes a bad prosthetist?,” I pressed.
“You do shitty work.”
“What’s shitty work?”
“Your patient doesn’t walk.”

The conversation ended there. Obviously, this brief conversation does not offer a very detailed picture of what makes a good or bad prosthetist although it does illustrate that prosthetists connect their care to their patients’ well being. Things are rarely this clear, however. An amputee may not be able to or want to use her prosthesis even if her prosthetist is brilliant and, conversely, may successfully use a shoddy limb made by a prosthetist with poor clinical skills. But Cliff’s stark connections beg questions about what kinds of clinical work is involved in getting the patient to walk. In hindsight, I wish I had then asked what, exactly, is good work? What is good care?

As suggested by the previous chapter, prosthetics care is much more than the prosthesis itself. I argued that the increasing management of care and cost containment strategies contribute to the reification of prosthetics caregiving as technology. I concluded by briefly noting that this has very real implications for what care amputees receive, and called for further attention to the praxis of care as a means confronting the alienation resulting from the management of care. Whereas the previous chapter addressed the reification of care from the prosthetist’s perspective, this chapter shifts the focus to the objectification of experience in clinical transactions.

The Clinical Transaction

Sean and I were collaborating on an experimental prosthesis and were ready to begin the process of casting, making, and fitting the prosthesis. We skipped the patient exam, the usual starting point for the collaboration, because we were already acquainted and had a design in mind, and proceeded straight to casting. In a patient exam, he would have asked me about my age, height, weight, cause and date of amputation, general health, illness complications, physical activity level, and lifestyle. Then he would have palpated my stump to check a number of physical characteristics. On a below-knee amputee, for example, characteristics such as the shape of the stump, prominent bones, extra tissue or loose skin, sensitive areas and padding at the end of the stump, and knee joint stability and range of motion, among other things, help indicate what kind of prosthesis may best suit an amputee. Although personal and social factors such as age, occupation, activity level, health, body image, and physical environment are perhaps ultimately more important, prostheses are physically, as well as socially, relative to amputees, their bodies, and the contexts of their use. The physical characteristics of an amputee’s body and stump, while not determinant of the clinical process, are important nonetheless.

The patient exam is primarily a way for the prosthetist to become acquainted with their patients within the broader context of their health and lifestyle. On an immediate physical level, it is an opportunity to make a visual and tactile inspection of the amputee’s stump and body, which will assist the prosthetist in mapping the landmarks of his or her stump while casting them. Landmarks are the physical characteristics of a stump that are more or less topographical and that must be considered when fitting a socket to encase the stump.

As we began the process of casting, Sean had me pull a thin cloth sock onto my stump and took measurements of length and circumference at intervals along the length of it. Dipping a grease pencil in water, he marked the major landmarks of my stump onto the casting sock so that they will transfer to the inside of the cast later and help guide him in modifying the cast. This process of marking is a literal mapping of landmarks on patients’ bodies, creating a geographic representation of strengths and vulnerabilities, places on the body which will bear weight and places that will hurt if subjected to too much pressure. This process is difficult to do accurately, but crucial to making a comfortable prosthesis. It’s not uncommon for experienced and skilled prosthetists to end up with markings slightly off-target or with inaccurate measurements, which adds to the difficulty of accurately fitting the socket.

Prosthetists usually cast by hand, but Sean expedited the process by using a pressure casting system on me. Pressure casting is a relatively new development in the field and has not yet been widely adopted. Prosthetists are notoriously pragmatic about adopting new technologies unless they are more efficient for the prosthetist or will make their patient more comfortable. Pressure casting creates a uniform, well-shaped cast, but at the expense of the tactility highly valued by prosthetists, so it is only sporadically used. He grabbed a couple of rolls of plaster of Paris bandage from a cabinet and, unwrapping one and dipping it in warm water, began wrapping my leg in warm plaster. When the plaster bandage completely covered my knee and stump, he directed me to insert my leg into the pressure casting unit—basically an inflatable, cylindrical bladder—and pumped up the unit to apply even pressure around my leg. When the cast had dried, we pulled it off and checked to ensure the grease pencil marks matched up with their corresponding landmarks inside the cast.

Sean filled the finished cast with plaster and gave me the tedious chore of stripping the embedded plaster of Paris after it hardened, leaving a solid, positive model of my stump. He then sculpted the cast into a desirable negative image of the socket, using rasps and other tools to do the modifications. After smoothing the cast, Milton and Noah, the shop’s two technicians, pulled a check socket (a test version) by wrapping the cast in a soft, heated sheet of polyethylene and applying a vacuum. They used an air hammer to remove the plaster from the inside of the socket while Sean attached a pylon and foot, and put the limb in bench alignment. Bench, or static, alignment sets the prosthesis in a neutral position which provides a reference point for later aligning the prosthesis to the patient’s body during dynamic alignment.

Alignment refers to how the prostheses is positioned and moves in relation to the amputee’s body. A certain degree of alignment of joints and limbs to each other is embodied common sense: it would be difficult to walk with your foot pointing backwards and hard to feed yourself if your forearm is too long. But aligning prostheses is a bit more nuanced. Dynamic alignment is the process of prosthetist and amputee working together to mechanically manipulate a prosthesis so that it is aligned to the amputee’s limb and body in such a way as to allow for intuitive use. In theory, as prosthetist learn it in school, alignment is based in biomechanical principles, physiology, and—for lower-extremity amputees—the concept of normal gait. In practice, it more or less boils down to a combination of normal gait, symmetry, subjective comfort, and whether the amputee is happy enough with the alignment to comfortably use the prosthesis in everyday life.

It was now time to fit and dynamically align the prosthesis. As we entered the fitting room and closed the sliding door behind us, we shifted roles from prosthetist and researcher to clinician and patient. Half kidding and half seriously, Sean began to speak in a more clinical tone, addressing me as Mr. Kurzman and giving gentle but authoritative descriptions and instructions about the new leg. After removing my everyday leg, I pulled silicone and cloth socks onto my stump and donned the prosthesis. I stood up, shifting my weight back and forth to gauge the height, trying to gain a sense of balance on it. I thought about how the socket felt and how it bore my weight as I shifted onto and off of it. Sean, sitting on one of the stools with caster wheels that seem to occupy every prosthetics shop fitting room, checked my height, first visually and then tactilely by uncomfortably digging his fingers into the flesh above my hips. As I stood still, he scooted around me to check the pylon, making sure it was perfectly vertical from both front and side perspectives.

I stood up, shifted my weight around, and began to walk in the parallel bars. I didn’t get very far, though, before the fiberglass tape binding the check socket to the pylon let out a loud ripping crack. After a quick repair, I walked in the bars for a few minutes and, quickly getting a feel for the limb, moved out of the fitting room and started trotting up an down the hallway. I tried to walk evenly and smoothly, looking straight ahead, and paid attention to where my body was and how it was moving. I focused on trying to walk consistently and paid attention to how the socket fit and how I was walking. Sean hunkered down on his stool at the end of the bars and watched me walk toward him, looking at where the pylon was at mid-stance when the foot was flat on the floor and I had my full weight on it. Then he scooted to the side and watched the prosthesis from a side view, making sure it was vertical at mid-stance from this view, too. How were my feet rolling over during the gait cycle? Was my trunk leaning after heel-off? Meanwhile, Sean gazed intently at my feet and body, asking himself similar questions, while Noah and Milton, the shop’s two technicians, leaned out onto the hallway and cracked jokes about the prosthesis hurting.

He motioned to me after a few minutes of this to sit down and remove the prosthesis. I peeled off the layers of socks and silicone, and Sean inspected my stump for redness, a sign of excessive pressure and friction. He also used the back of his hand to check skin temperature on the weight bearing areas. The fit was fine, but the alignment was off so Sean used a hex tool to make the adjustments. In a common modular, endoskeletal prosthesis, the socket and foot are connected using a hollow aluminum pylon and a pair of titanium pyramids, or mounts, one at either end. By adjusting the hex screws in the mounts, the prosthetist can make planar or angular adjustments in how the foot and socket are positioned in relation to each other. A few slight twists of a tool can radically change how one’s foot feels, how one’s leg is aligned under the body, and how it feels to walk.

After a few minutes of adjustments, I called to Sean’s attention that something didn’t feel quite right about the prosthesis. He posed questions in an effort to pinpoint the problem. Where does it hurt? Does it feel like you’re walking up a hill? Does it feel like you’re walking into a hole? We moved to the workshop in the back of the facility, where I removed the prosthesis and he made some further adjustments. I was soon pacing the hallway again and we went through the cycle of walking, feeling, observing, questioning, and adjusting again. My attention focused on my legs and the effort of thinking about what it feels like to walk, and how to articulate how this feels, while Sean alternately observed my legs, face, and body language. We repeated the process over and over, loosening tight areas of the socket, plantarflexing or dorsiflexing the foot, adducting and abducting the socket, and toeing the foot in and out. “Is that better or worse now? Or the same?,” he asked after each adjustment.

Finally, we reached that moment when the prosthesis feels right and I stopped thinking about walking because nothing felt remarkable about it anymore. I began walking at a faster pace, stopped looking at my feet, and my face exuded the expression of having just figured something out. Sean noticed this, as did Noah and Milton, especially when I cheered and raised my arms like a goalpost. We got it right, the socket was comfortable and the prosthesis correctly aligned. Back in the fitting room, we were chatting about the process and its difficulties when Sean remarked thoughtfully, “you know, there’s no language for this…”

I believe that Sean’s remark may be interpreted as having two meanings and the remainder of this chapter is concerned with their exegesis. First, somewhat literally, that it is very difficult to verbally communicate about the subjective experience of fitting, aligning, and learning to use a prosthesis because, as Sean said, “there is no language for this.” This chapter suggests that amputation and the process of fitting, aligning, and learning to use a prosthesis is analogous to chronic pain. Amputation is a sudden and shocking form of disembodiment that disrupts previously taken for granted meanings of our bodies and lives. Like chronic pain, it resists language and biomedical objectification, and is essentially a subjective experience. Yet pain seems to have an agency of its own to wreak havoc on the body. The result is that the body in pain and discomfort—or simply learning how to walk again—becomes phenomenologically externalized, objectified, and “personified as an aversive agent.” (Good 1994: 124) I argue that a definitive aspect of prosthetics care is a collaborative effort by amputees and prosthetists to reconstitute meaning in amputees’ bodies, lives, and the immediate experience of using a prosthesis.

Secondly, I think Sean’s remark can also be interpreted as meaning that there is no common language shared between amputees and prosthetists with which to describe the experiences of amputation, the process of being equipped with a prosthesis, and learning how to use it. Paradoxically, within a clinical context, the phenomenological objectification of the body in pain and discomfort is the opening to the clinical objectification of the body and medicalization of the patient. The body experienced as an “aversive agent” is clinically treated as such, as well. Medicalization underlies nearly every aspect of this collaborative meaning making, including patient exams, gait training, and blaming patients as irresponsible and noncompliant. Medicalization is a crucial aspect of prosthetist-patient negotiations of meaning, yet it is often partial and incomplete. Clinicians may be ambivalent, and amputees find various ways to respond to it, such as recouping power in objectifying exams or “talking back” to clinicians. In a rehabilitation field that alienates its patients from their experience by not providing or even allowing any space for expression of loss and distress, amputees may technologize their distress by expressing it through complaints about their prostheses. These exchanges are more dialogic than the unidirectional models of top-down medicalization or bottom-up narrativization of experience frequently deployed in medical anthropology analyses of the clinic. And so the second component of my argument is that this collaborative effort to reconstitute meaning in prosthetics care is based in a dialogue between medicalization and patients’ responses to it.

There’s No Language for This…

In The Body in Pain, Scarry argues that “[p]hysical pain does not simply resist language but actively destroys it” (1985: 4). The book’s first chapter discusses torture and describes how “the subjective characteristics of pain are objectified.” (Ibid.: 54) Pain is aversive and becomes external to the body, and we experience it through its “internal agency” in our bodies as well as through its objectified “external agency.” The boundary between internal and external dissolves and pain “monopolizes language, becomes its only subject” before “the coherence of complaint is displaced by the sounds anterior to learned language.” (Ibid.) Pain not only destroys language, but our consciousness in totality.

Leder makes a similar argument from a more explicitly phenomenological position in The Absent Body. Leder discusses pain in the context of the phenomenological paradox of the “dys-appearing” body and the question, how can the body be absent from human experience when experience is to embodied? In an example of a tennis player suffering the pain of a heart attack, Leder describes how pain first effects a “sensory intensification” in which we become acutely aware of a part of our bodies of which we’re usually not consciously aware (1990: 71) and, then, effects an “intentional disruption” in which it occupies the whole of our consciousness (Ibid.: 73). Our bodies eventually emerge as an “alien presence” external to our bodies and “foreign to the self.” (Ibid.: 73) As Leder puts it more simply, we no longer “are” our bodies; we “have” bodies. The result is a split between body and self in which the body is objectified by the self and we act toward our bodies rather than from them. Leder refers to this as the “dys-appearance” of the body in which it appears prominently as dysfunctional or in an aversive state of breakdown (Ibid.: 83-4). Finally, the body is absent in a dual sense, which Leder refers to as the “absence of an absence”: the normally taken for granted body (”primary absence”) becomes absent from the experiencing self (”secondary absence”).

Both Scarry and Leder describe an ambiguous quality of pain in which our bodies become simultaneously external and internal to our experiencing selves. Scarry describes how pain is experienced subjectively in the body, which then become objectified as an external agent acting upon our selves. This ambiguity blurs the previously clear boundary between subjective and objective and wrecks our ability to objectify the experience of pain through language. Leder describes a similar dynamic in which bodies in pain and discomfort are externalized from our experiencing selves and “dys-appear.” On a philosophical level, we can view amputation and the process of fitting, aligning, and learning to use a prosthesis as a “dys-appearance” of the body using both of these approaches.

Pain is an imperfect analogy for prostheses, which are not necessarily painful. In fact, the primary goal in fitting and aligning a prosthesis is to arrive at subjective comfort for the amputee. But in the course of fitting, new prostheses occasionally hurt and are often uncomfortable. Stumps are perplexing and delicate new body parts, phantom limbs are somewhat disconcerting and distracting (if not painful), and prostheses feel totally unfamiliar. A surgically created body part which was not evolutionarily designed to bear weight is now bearing weight (for lower extremity amputees), and one’s stump is encased in cloth socks and plastic. It is all so supremely alien that it is extremely difficult to describe the sensation of the experience.

Even when prostheses don’t hurt, pain is always present in the background and, in my experience, seems to be a universal starting point to fitting artificial limbs. Whether being fit for a prosthesis in the United States, India, or Cambodia, the first question put to me has always been something to the effect of, “does it hurt?” This question is not only significant as an illustration of the importance of pain as a bottom line diagnostic tool, but as an example of the importance of eliciting subjective feedback from the amputee using the limb. After all, the prosthetist cannot always tell if the prosthesis hurts, and pain and discomfort are essentially part of the subjective experience of using a prosthesis.

In light of the strangeness of the experience, it is not surprising that new amputees are frequently rendered inarticulate about the subjective experience of prostheses. Amputation is a profound loss and new amputees experience both initial shock as part of the grieving process and more lasting disruptions to their body image and self-image (Wallace 1995; Winchell 1995). Partly in collaboration with their prosthetists, as I will discuss later in this chapter, experienced amputees eventually remake some meaning and understanding of their bodies and prostheses, and learn what feels right about a prosthesis and—hopefully—how to communicate this to their prosthetist. But for newer amputees, it’s often frustratingly difficult to know what a prosthesis should feel like and to articulate this to the prosthetist. Even though “it”—the prosthesis—is subjectively experienced, “it” is also alien and external to the body and difficult to objectify through language. A prosthesis may be one’s new limb for new amputees, but it looks and feels like a hunk of metal, plastic, and rubber rather than one’s limb.

Chronic pain and illness are increasingly important topics in clinical medical anthropology, and B. Good brings the discussion of pain into a clinical context in his case studies of Brian, who experiences chronic pain from TMJ (Good 1992, 1994). Good also suggests that “pain has agency” and describes how Brian conceptualizes pain as “a demon, a monster, lurking within, banging the insides of his body. Pain is an ‘it’ which ‘erupts in various places in your body,’ a force which streaks around the body, which Brian seldom feels able to control.” (Good 1994: 124-5) “At the same time,” he continues, “pain is a part of the subject, a ‘thing’ of the body, a part of the self. As a consequence, the body itself becomes personified as an aversive agent. It is invested with menacing autonomy.” (Ibid.) Good, like Scarry and Leder, argues that pain remains part of subjective experience while transforming the body into an external agent, but also expands upon the specific relevance of this for the biomedical clinic.

Good notes that “[c]hronic pain challenges a central tenet of biomedicine—that objective knowledge of the human body and of disease are possible apart from subjective experience” (Good 1994: 117; Kleinman, et al. 1992). Using Merleau-Ponty and Scarry, he argues that chronic pain resists biomedical objectification, as well as practices “designed to localize suffering in a discrete site of the body, a site which can be made visible and subjected to therapeutic procedures.” (Good 1994: 132) In this way, chronic pain unmakes the patient’s lifeworld, using Husserl’s concept of lebenswelt. Good hypothesizes that patients narrativize the origin and history of their pain to counter this unmaking and reconstitute their worlds. In a similar vein, Brodwin suggests that we can use “‘performance’ as a metaphor for the analysis of experience” and the social representation of the experience of pain (Brodwin 1992: 201). Brodwin also views pain as a private, subjective experience in which the pain, itself, is the performance. But he discusses the familial and employment relationships of a woman suffering from chronic pain, and uses the concept of “social performance” to describe how she presents her symptoms in the context of social relationships. Following B. Good (1994) and Brodwin (1992), we can consider narrative and performance as key means by which amputees communicate the experience of using prostheses in the absence of language.

Medicalization

The irony of the ambiguity of pain is that while discomfort may resist language, it seems to invite biomedical objectivism. Like chronic pain, the experience of using a prosthesis is subjectively felt in the body, which then appears as an external force acting upon our selves. This blurring of the body between a subjective source of experience and objective agent disrupts our ability to objectify the experience of pain and discomfort through language. In a clinical transaction in a prosthetics shop, this means a great deal of difficulty for an amputee in communicating how her prosthesis feels to the prosthetist. Using Leder’s term, the body “dys-appears,” or appears prominently and dysfunctionally, externalized from our experiencing self. In these moments of dys-appearance, when our selves objectify our bodies, clinicians do, as well, by asking their patients to “perform” their everyday use and experience of their prostheses.

One basic form of patient performance is to simply use the prosthesis by demonstrating how they put it on, walk around for a while, and then take it off to allow the prosthetist to examine their stump. One day Marcus and I went on a house call to Mr. Galla, who was having difficulties putting on his prosthesis. The first thing Marcus did was have Mr. Galla take off his prosthesis and then go through the process of putting it on, standing and walking on it, and then remove it. While watching him don the limb, Marcus noticed that Mr. Galla wasn’t pulling hard enough to insert his stump entirely in the socket and thus the prosthesis wasn’t securely in place. This was a fairly simple problem, so Marcus described the process and then physically guided Mr. Galla through the performance again to show him how to correctly pull on his prosthesis.

Another form of performance is less deliberate on the amputee’s part and entails prosthetists reading their patients’ bodies for signs. As mentioned earlier in the description of the clinical interaction between Sean and me, prosthetists read their patients’ facial expressions, walking speed, and other body language in addition to analyzing their gait. Amputees undeliberately reveal the discomfort of their prostheses by looking at their feet, scowling, or possibly favoring one leg. Prosthetists also commonly read the skin on their patients’ stumps for signs of discomfort by checking the temperature of the skin with the back of the hand, looking for redness, or checking for textured impressions from stump socks. These are all signs of tight spots in the socket where pressure needs to be relieved. Amputees’ bodies become embodied performative texts which prosthetists scan for signs of discomfort or pain. These “landmarks” are also the basis for deciding what is the most appropriate type of prosthesis for an amputee and how to most accurately fit him. Marcus one day remarked that bodies indicated or contraindicated certain styles of sockets and suspension systems for prostheses. Mr. Galla’s prosthesis, for example, was a suction socket, which requires a good deal of effort and he was having difficulty putting it on. Marcus pointed out that this style of socket and prosthesis was inappropriate because Mr. Galla had a heart condition and shouldn’t exert himself so strongly. His health contraindicated a suction socket, but his doctor was not knowledgeable about prostheses and had written a very specific prescription.

The performances of the patient exam, casting, and fitting and aligning the prosthesis are undoubtedly an objectification of amputees’ lives and experiences as collections of bony protuberances, raw nerve endings, and observable movements. But despite attempts to objectify amputees’ bodies, medicalization is often incomplete and negotiable.

When we had finished fitting the cost containment leg, Sean and I sat in the shop’s break room and I listened and jotted notes as he told me how he was able to read my body, scanning my movements for signs of success and distress, during alignment. Rebecca joined us and we continued the discussion about the difficulty of clinical communication. In light of this gap in clinical communication, I suggested an admittedly utopic solution: that there should be some common language for clinical use that encompassed the subjective experience of using a prosthesis, especially since amputees strongly value communication in clinical interactions. Rebecca disagreed and argued that prosthetists simply need good observation skills. She felt there is a language for this—biomechanics—and subjective experience is unimportant because it can’t be expressed in biomechanical language.

This blunt dismissal of her patients’ experience is more typical of Rebecca as an individual practitioner than of prosthetists in general, but it hints at the generalizable tendency to extract objective knowledge of the patient’s body from that individual’s physical performance and transform it into a biomechanical diagnosis and repair (Kleinman 1995; Redding 1995; Scheper-Hughes and Lock 1987; Taussig 1992). Kleinman describes this under the rubric of disease without suffering and treatment without healing (1995: 31-4). Biomedicine is based on a series of dichotomies in which the clinician’s object of focus is the material rather than subjective experience. “[T]he doctor is expected to decode the untrustworthy story of illness as experience for the evidence of what is considered authentic, disease as biological pathology.” (Ibid.: 32)

However, an important difference is that prosthetists do not cure disease. This is implicit in the field—that prosthetists equip their patients with tools for living rather than curing the lack of limb—but prosthetists also acknowledge this explicitly. John Michael, a well-known prosthetist, gave a presentation at the 1996 Amputee Coalition of America meeting in which he offered tips for how to choose a prosthetist and discussed strategies for successfully collaborating with them. One of his concluding points was that if prosthetists could give you back your limb, they would, but they have limitations and mutual communication and cooperation are essential for quality care. Another important difference between prosthetics and this clean formula of biomedicine is that prostheses, like chronic pain, resist biomedical objectification. While the externalization of the discomfort of using prostheses invites objectivism, it remains entrenched in subjective experience and resists total extraction and translation into biomechanical diagnoses. Observation skills are certainly important to prosthetists in diagnosing and correcting observable problems. But, like chronic pain, reports of discomfort in using a prosthesis are not always readily measurable or observable. The result is that, although prosthetists may be dismissive of their patients’ subjective feedback at times, they can’t necessarily objectify their patients’ concerns as biomechanical problems with technical solutions.

There is an implicit, if not always respectful, recognition that subjective satisfaction is often the bottom line if the patient is to be satisfied with the clinical transaction. For example, Cliff was working with a new patient named George, whose previous prosthesis (which had been made at another shop) was, in Cliff’s opinion too short and causing him gait problems. So he made his new prosthesis taller at what he believed to be the correct height. George, on the other hand, adamantly felt that his new leg was too tall but couldn’t articulate a more specific complaint as to why. It didn’t hurt; it just didn’t feel right, but he couldn’t quite express why. They were both irritated with each other, and after this stalemate went on for a while Cliff turned to me and two physical therapy students visiting the shop for the day and hissed, “half the difficulty of prosthetics is understanding what the fuck the patient is talking about.” Nonetheless, in lieu of any observable phenomena indicating the discomfort, he did not dismiss George’s complaints.

One way in which medicalization remains partial is when amputees sometimes recoup a sense of empowerment from clinical situations that appear to be unilaterally objectifying. The prosthetics-orthotics school employs professional patients in order to offer its students opportunities for clinical training. In addition to their didactic lectures on prosthetics, biomechanics, anatomy, and a multitude of other topics, the students spend a significant portion of their time in the lab course learning to make prostheses through active practice. At the completion of each limb, the patients perform the prosthesis as their nervous student stands nearby to have his or her work critiqued and graded by the instructors. Due to a number of factors, such as the demographics of the patients who go to the adjacent prosthetics clinic in the rehabilitation center and the confluence of race and class in Chicago, the vast majority of the professional patients are working class African-Americans from the south side of Chicago. I was ambivalent about the power dynamics of the arrangements in which white health care professionals trained by practicing on poor, elderly African-American.

But my hesitation diminished when it came time to work with the students on the fifth and final below-knee prosthesis, the “crazy leg.” During the first four below-knee prostheses, the instructors assign the students specific types of prostheses to make. But for the fifth limb, the students can use whatever style they believe is most appropriate for their patient and have free license to cosmetically decorate the limbs. The result is a beautiful cacophony of colorful, creatively designed limbs. The Chicago Bulls basketball team logo was a clear favorite among the patients, no doubt because the Bulls and Michael Jordan were a symbol of empowerment for African-Americans in Chicago. I mustered the courage to ask a few of the patients to sign my photography permission forms, offering free copies of their photographs in exchange for their permission. I didn’t plan on photographing many people at first, but it soon became clear that others were offended and excluded: “I heard you’re takin’ pictures. Don’t you want to photograph me, too?” People began asking to be photographed and a number of them mentioned they wanted to be able to show their friends and families what they did during their days at the school “showing the students about prosthetics.”

The critique went well and the prostheses were beautiful. I distributed photographs a few days later and thought this was the end of it. But one of the patients who was a bilateral amputee, below-knee on one side and above-knee on the other, passed his photos around among the above-knee professional patients a couple weeks later. In short order, I was recruited as the unofficial photographer by most of the above-knee patients, as well. I didn’t understand at first why people wanted to be photographed in a situation where they were clearly being medicalized and put on such public display. But people mentioning that they wanted to show this to their friends and families reminded me of an earlier conversation with a couple of the professional patients whether they enjoyed it. They both seemed surprised at the question and answered that it was fun and it made them feel useful. Plus, they said quite explicitly, they were contributing to the future of the prosthetics field by teaching the students.

While I am still ambivalent about the politics of mostly white health care professionals training on poor African-Americans because marginality invites medicalization, the patients are in a very powerful position of teaching the students how to be prosthetists and most of them know it. And perhaps just as remarkable, the instructors and students at the school acknowledge this, as well. The instructors are very respectful of the patients and clearly value their subjective experience during critiques, which also teaches the students by example. Some of the prosthetists and orthotists with whom I worked, even years later, remember their patients from school and can recount how they showed them how to align their prostheses.

Clinicians can also be ambivalent in their medicalization of their patients at times. The concept of “normal” is an important one in the prosthetics field, particularly to the notion of “normal gait.” Although prosthetists don’t often explicitly discuss normal gait in practice, therapists, gait analysts, and engineers do use the idea, though not without some ambivalence. I first saw this while attending a gait analysis conference at a local children’s hospital. The conference was a half-day session of presentations on recent and current gait analysis projects in the Chicagoland area. The papers were very interesting and most addressed issues related to concepts of normal and various pathological gaits. But when the keynote speaker gave her presentation, she repeatedly and physically placed the word “normal” in quotes by raising her hands and pulling down with her index and middle fingers to signify quotation marks. I later mentioned this to Barbara, one of the graduate students from the engineering lab, who was not surprised. She noted that the head of the lab, encourages his graduate students to be aware of the social and moral, as well as statistical, connotations of normality, and to avoid conflating these meanings.

On another occasion, I accompanied Sean to the weekly orthotics-prosthetics clinic at a hospital on the northwest side of Chicago. One of the patients was a man from West Virginia with a particularly severe case of diabetes. He had already had both feet and one hand amputated, and came to the clinic to have the clinic team (composed of Sean, a physician specializing in physical medicine and rehabilitation, and a physical therapist) check his walking and ability to perform activities of daily living, such as shaving, washing, and brushing his teeth with his new arm. As we left, the physical therapist corrected the man’s walking, commenting that he had to pick up his right side in order to walk more normally. She also used her fingers to pull quotation marks in the air when saying normal. On our way out of the hospital, I asked Sean if he noticed this. I was a bit wary of the quotation marks because they are often a means to use a word with multiple and loaded meanings, but also to absolve the speaker or writer of the responsibility of having invoked the less desirable meaning. Sean noted that professionals in the field use the term to mean average or common in a statistical sense, but agreed that it was problematic given the other meanings of normality.

Another way in which medicalization is partial at times is when amputees “talk back” to their prosthetists. Not infrequently, new amputees talk back to their prosthetist or doctor (this is much less common among longer-term amputees) by challenging their prosthetist’s choice of componentry, blaming their doctor for their amputation or recovery, or simply deciding to not use their prosthesis. I first met Dijana, an elderly Croatian woman with a recent above-knee amputation, while accompanying Sean to a regular hospital prosthetics clinic. At the previous clinic, she had complained of painful sensitivity in her stump which prevented her from wearing her prosthesis, so Sean had shown her some therapies to desensitize her stump. She had returned to the clinic to check in and reported that the therapies didn’t help and her stump was still too sensitive to use a prosthesis. Sean mentioned some additional ideas, but Dijana made it clear that she wasn’t all that interested in using her prosthesis, regardless. The doctor, physical therapist, and Sean gently pushed her on the issue, but she held her ground and explained that she was perfectly capable of living independently while using a wheelchair and didn’t see much advantage to walking with her heavy, cumbersome above-knee prosthesis. The clinic team accepted this and wished her well.

Although Dijana was on collegial terms with the clinic team, she struck a more adversarial tone when I later interviewed her at her home. Her leg had been amputated six months earlier because of circulation problems (and what turned out to be diabetes). She felt the amputation was a shock to her body and contributed to a sense of insecurity she carried from immigrating to the United States as a refugee, a lifetime of financial insecurity, and the recent death of her husband. Walking left her feeling insecure, too, because she was afraid of “freezing up” and falling because of poor balance. While Dijana said she wanted to walk, she felt that she didn’t need to walk. Paradoxically, she also felt there was stigma attached to prostheses and preferred her wheelchair. She is able to bathe and use the toilet herself, and hires a Croatian girl to help out around the house once a week. She showed me her kitchen, which she nicely remodeled to accommodate her cooking in a wheelchair. She spoke of the wheelchair as an opportunity to sit peacefully and think about her life and her husband.

The hospital scheduled physical therapy for her following the surgery, but she stopped therapy after a couple sessions because she felt the therapists were pushy and condescendingly treating her “like a little old lady.” She once challenged her doctor about the necessity of therapy, to which he responded by sarcastically asking, “are you a PT?” No, she responded, but the physical therapists only know books, and she knows people—and herself—and didn’t want the therapy. She was not only deeply skeptical of the hospital’s financial motivations for providing therapy in order to bill her insurance, but of her doctor’s stakes in making an elderly woman walk as a “medical achievement.” “I’m not going to kill myself so that the doctors can see a 73 year old woman walk. I’m not going to tap dance.”

Compliance

Despite the resistance of prosthetics to objectification and the partiality of medicalization, prosthetists often operate under a model of patient compliance. On day in Beinhersteller’s, Cliff and Marcus were bemoaning the prospect of Mr. Galla coming in that afternoon. They felt that Mr. Galla was one of their more difficult patients to work with because he “doesn’t try,” or put any effort into learning to use his prosthesis, yet he called the shop almost daily to complain to Cliff. They were frustrated at what they perceived to be Mr. Galla’s total disengagement and refusal to accept responsibility for his own rehabilitation. I began asking about the difficulty of dealing with this, and Simon interjected that he had just returned from a house call. His patient was a middle-aged, obese man who had lost a leg to complications from type two diabetes. Noting the candy wrappers in the house, Simon doubted the man was making an effort to lose weight, exercise, or otherwise change his lifestyle in order to prevent further diabetic complications or amputations. His current problem was that he had been incorrectly propping up his stump while sitting and laying down, his knee had become hyperextended from being straightened out for long periods of time, and now his prosthesis was misaligned. In exasperation, Cliff joked, “let’s just shoot him.” This sentiment is indicative of a broader phenomenon of mutual blame and misunderstanding in which prosthetists are often frustrated with their patients who, from their perspective, do not proactively manage their diabetes and fail to take responsibility for their own health.

I attended a prosthetics clinic at Cook County Hospital with Sean in the Spring of 1997. The doctor and several prosthetists from Chicago shops all volunteered their time, and the patients, mostly African-Americans from the west or south sides of Chicago, were all poor people in need of a prosthetist. The hospital is renown among both health care professionals and urban poor people in Chicago for providing quality care in the face of dire public health budget constraints. Nearly all the patients shared in common a connection between their amputations and environmental factors endemic to extremely marginal urban poverty, such as dangerous living conditions and lack of adequate health care or public health education. For instance, one woman told me about the garden she kept just outside the housing project in which she lived. The local drug dealers and gang members littered her garden, in which she grew collard greens and other fresh vegetables, with debris. One day in her garden she cut her foot on a sharp piece of drug-use debris, quickly developed an infection, and subsequently had her foot amputated. This resonated with other stories I had heard from poor or working-class African-Americans, whose amputations were more likely related to urban violence or dangerous jobs.

The clinic team worked its way through the two dozen amputees, spending as much time as they could with each one, deciding on a treatment plan, and moving on to the next. There was an amazing diversity in how people responded to their loss. One elderly African-American man had recently had a partial foot amputation in which the toes and metatarsals are amputated. He had somehow fallen through the cracks of the public health care system and was sent home from the hospital without a follow-up plan to see a physical therapist, a prosthetist, or even a physician. After a few months, he felt that he should probably see a doctor just to make sure everything was okay, and was directed to the prosthetics clinic. His chief dilemma was how to wear a shoe when he had lost the front part of his foot. Without toes, the shoe kept slipping off of his foot, so he tied a couple plastic grocery bags onto his foot with string to keep his foot clean and dry. It was raining that day, and he took the bus to the hospital with a shoe on one foot and plastic bags on the other. The team was shocked and impressed, and made arrangements to have him fitted for a partial foot prosthesis that would help him walk more easily and to keep a shoe on his foot.

On the other end of the spectrum, there was a man with a below-knee amputation who came to the clinic because he had developed a large abscess over his fibular head. The abscess was so deep that it actually revealed the fibular head (the top of the fibula, felt as the bump on the outside of the leg just underneath the knee), which was abrading against the inside of the socket of the prosthesis. It had started with an ill-fitting socket which didn’t provide enough relief for the fibular head, and had lead to a wound from all the abrasion. The man had severe neuropathy (a lack of sensation in the extremities, a common complication of diabetes due to lack of oxygenated blood flow) that he had almost totally lost feeling in his legs and had a dangerous capacity for pain. Thus, he was able to walk with a huge hole in his leg, his bone grinding against the inside of his prosthesis with every step, but barely noticing any discomfort. What was more disturbing to the team was that he didn’t seem to understand the gravity of the situation. The team debated taking his prosthesis from him and sending him home on crutches, but decided instead to impress upon him that he could develop a bone infection if he didn’t stop walking immediately, seek medical treatment to heal the abscess, and see a prosthetist to adjust the fit of the socket.

Prosthetists tend to view the clinical relationship as a contractual agreement into which both parties have entered. Their understanding of this agreement strongly resonates with Parsons’ classic 1951 description of the sick role in which the sick person is exempted from the responsibilities of her everyday social roles in exchange for the temporary responsibilities of the patient. The sick person must acquiesce to being taken care of, and, in exchange, is obligated to get well again. The key aspect of this obligation is to seek out and cooperate with “technically competent help.” (1951: 436-7) From a prosthetist’s point of view, a patient who fails to accept responsibility for managing their diabetes or learning how to use a prosthesis is failing their responsibilities as a sick person. The problem here is that Parsons’ model and prosthetists’ understanding of this contractual agreement are based upon acute illness, and neither diabetes nor amputation are acute illnesses. The result is that prosthetists expect their patients to comply with a contractual agreement to “get better” from amputation, which, of course, is not possible.

This crucial difference has not been lost on diabetes educators, and recent research in diabetes care reflects a growing awareness of problems with applying traditional biomedical models of compliance to patients with diabetes. As rates of diabetes increasingly effects communities of color in disproportionate numbers, one area of research is on cultural factors important to how Latinos, African-Americans, Pacific Islanders, and Native Americans manage diabetes and treatment regimens. In a significant shift, much of this work does not formulate the issue in terms of “cultural barriers” but, as the title of one paper (”Culture Counts: Why Current Treatment Models Fail Hispanic Women with Type 2 Diabetes”) suggests, place the onus on health care educators and providers to redesign their approach in order to address their patient’s cultural needs (Anderson, et al. 1998; Blanchard, et al. 1999; Brown and Harris 1999; Oomen, et al. 1999; Roubideaux, et al. 2000; Wang, et al. 1999).[1]

Although there is a general shift from compliance to adherence in diabetes care, another area of research argues that both of “the constructs ‘compliance’ and ‘adherence’ were counter-productive because they both construed the problem to be the patient’s behavior” (Glasgow and Anderson 1999: 2090). The authors of a letter titled “In Diabetes Care, Moving from Compliance to Adherence is Not Enough,” written to the journal Diabetes Care, argue that “[d]iabetes care requires a truly collaborative approach” because “[u]nlike the treatment of acute illnesses, patients with diabetes are fully responsible for the self-management of their illness” (Ibid.: 2091). What they mean by this is that people live with diabetes as well as suffer from it; they make daily decisions about what to eat, whether to exercise, and so on. Demands that diabetes patients comply with a treatment regimen may ultimately fail in part because they reinforce what clinicians refer to as “external locus of control.”

Technologization

Presentations of complaints about the fit of a socket or the alignment of a prosthesis usually reflect actual physical discomfort. However, many recent amputees learning to use their first prosthesis naturally use the technology as a medium to express the ongoing difficulties of learning to live as an amputee. This is especially the case for those experiencing particularly difficult adjustments to being an amputee. There is very little space in the rehabilitation process for expressing the sense of loss from an amputation or the frustrations of prostheses. Many amputees carve out their own space for this by expressing their distress through complaints about their prosthesis. Technologization is a bidirectional form of communication, and prosthetists also use the technology as a means of reassuring their patients and healing their distress. For example, Lance and Sean had the longest clinical relationship I witnessed during my field work, based largely on technologization.

Lance was 80 years old when I first met him at a weekly clinic at a Chicago hospital. He had recently lost a leg below the knee due to complications from peripheral vascular dysfunction. He was having a generally difficult time adjusting to the amputation and called Sean every week—sometimes daily—with complaints about his prosthesis. He and his wife were always very apologetic about bothering Sean, who eventually established an informal weekly house call to hear Lance’s latest concerns and make minor adjustments. Lance felt literally dis-abled, but excluded his age and health complications as relevant factors and focused on the amputation, which he once described to me as affecting his life “like night and day.” He felt the loss of his leg rather acutely, frequently describing how helpless and out of control he felt; on one painfully poignant occasion in the shop, he pointed to his prosthesis and commented to his wife and me, “that’s the part of me they buried.”

Although Lance located his sense of painful disembodiment in the prosthesis, I believe that he was expressing his distress about feeling increasingly impaired and decreasingly out of control of his body through the medium of technology. Lance was born in Chicago to a working-c1ass, Polish-American family and left school before the 8th grade to help support his family during the Depression. Not surprisingly, he has a strong work ethic imbued with pride, masculinity, and self-reliance. He learned how to drive when he was 11 years old: one of his older brothers packed him into the family car, drove downtown to elope with his girlfriend, and left Lance to figure out how to drive the car home across Chicago by himself. He later put his driving skills to good use by working as a truck driver during the day and playing the concertina for eastern European wedding parties at night. He eventually worked his way into mechanic and engineering jobs, but always refused to let his wife work, feeling that a man should take care of his family. Now, with his amputation, a lifetime of values of masculine self-reliance had come into crisis and he expressed this through not trusting his prosthesis.

Lance used his stump and prosthesis as idioms through which to express his loss. Many male amputees have a phallocentric preoccupation with stump length, believing that longer is better. This is not the case, but it can lead to awkward anatomical comparisons in prosthetics shops. Lance was very concerned that his short stump was a disadvantage. Though this was not completely ungrounded and it probably did contribute to his feeling of medial-lateral instability, he was also afraid of falling and was hesitant to venture very far out of his house. He told me that he hated not wearing the prosthesis because he had “sit there like a dummy,” but had not yet learned to trust his balance or the prosthesis and didn’t like to use a walker or a cane, apparently because they visibly marked his impairment. While he can take care of himself, push a shopping cart, and drive a car—all very important activities to him—his calls to Sean had a familiar refrain of feeling unstable and off-balance on the prosthesis.

Lance’s visits to the shop and Sean’s house calls usually consisted of watching him walk, listening to him describe his fears of walking, making minor adjustments to his prosthesis, and mostly just reassuring him that he was doing well in spite of it all. Lance felt that that the prosthesis didn’t fit correctly, didn’t feel right, or that he wasn’t walking well enough, but his skin and stump rarely showed any signs of an ill fitting. So Sean would patiently listen and sometimes make minor adjustments to Lance’s prosthesis, using what prosthetists informally refer to as a “head fit.”

The head fit, also called “fitting between the ears,” is a powerful example of how prosthetists engage in technologization with amputees. It’s based on an implicit recognition that amputees are locating their distress in the prosthesis and that the complaint is less technical than it is psychological and social, expressed through a technical medium. The prosthetist’s response is to reciprocate by using the prosthesis as a medium for treating their patient’s distress. Ironically, I do not believe that amputees are usually aware that they are technologizing their distress, nor do prosthetists recognize that head fits are a means of healing their patients’ sense of loss and frustration. At times, prosthetists can be mildly derisive of the practice because they misunderstand it as an psychological maladaptation, but inconsequential and reassuring adjustments are a common practice in the field. During class at the prosthetics school one day, the instructor posed a series or challenging alignment problems to the students to develop their problem-solving skills. There was a pause when the students ran out of suggested solutions until someone called out “head fit!” from the back of the classroom. In other words, if you’ve run out of technical solutions, the problem might be a psychological one located with the amputee.

Sean occasionally head fit Lance by grinding out a small bit in his socket and showing him the dust in the socket to illustrate the alteration and improvement. Throughout their lengthy clinical relationship, Sean continued to head fit Leo as a supplemental treatment to listening to him, trying out various products and suspension systems, and complimenting his gait. Although this probably didn’t actually help Leo in any physical sense, the bidirectional communication enabled by their mutual technologization was very important in establishing a trusting clinical relationship and giving Lance a means by which to express his distress.

Technologization is a crucial means of communicating about the distress of amputation, and may be seen as analogous to Kleinman’s concept of somatization, which he describes as “the presentation of personal and interpersonal distress in an idiom of physical complaints together with a coping pattern of medical help-seeking” (1986: 51). In biomedicine, the body is a medium for this, but in the prosthetics field, physical complaints about the technology become the idiom and prostheses are the medium. Amputees often use the fit and alignment of the prosthesis as an idiom through which to address issues of loss, disruption, body image, physical function, and their standing vis a vis cultural values of abledness, self-reliance, and independence. In fact, much of the alignment process and clinical interactions in general is about technologization, in which prosthetics technology becomes the common ground for amputees and prosthetists to communicate about non-technical issues.

Scheper-Hughes has criticized Kleinman’s notion of somatization for describing it as a maladaptive behavior, rather than “as a collective and embodied response to the nervous political system.” (1992: 186) While the latter is a valid criticism, I disagree with her characterization of Kleinman and believe he describes somatization more as a coping mechanism to the maladaptation of healing in clinical settings. The kind of technologization used by prosthetists and amputees to communicate is somewhat similar. It doesn’t so much erase the social relations of care, as it acts as an idiom for them, perhaps akin to somatic culture (Scheper-Hughes 1992). Although one would hope differently when in rehabilitation, in practice, there is very little room for grief, loss, frustration, or adjustment in rehabilitation settings and prosthetics shops are no different. Although prosthetists are increasingly cast in the role of clinicians, they remain technology providers and have not cultivated counseling skills or “bedside manner” as have physicians. In addition, prosthetists become somewhat jaded to the suffering of amputation by merit of spending so much time with amputees. A part of the somatic culture of prosthetics shops is a sense that amputation is not difference but simply the ways things are: the loss of a limb becomes completely normalized. But as a result, amputees are forced to create and claim their own space in which to express the emotions and other non-technical issues which accompany amputation and prostheses. Technologization may not be a form of collective political response to medicalization, but it is hardly maladaptive.

The human relations are not replaced by a thing, but negotiated through it. Although prostheses are discrete pieces of technology, amputees and prosthetists collaboratively produce their meaning through the metaphor, performance, and technologization. The prostheses are an idiom or medium of communication, but are also made meaningful. They are both produced by, and sites of production for, meaning. In one sense, prostheses are socially constituted: the process of making a prosthesis is also a process of investing it with meaning; the construction of the prosthesis is simultaneously its social construction. In another sense, prostheses (and the bodies using them) are an effect of power; the process of clinical interaction is also one of medicalization.

Metaphor

In technologization, prostheses are metaphors for distress, but amputees and prosthetists also use other forms of metaphor to communicate. As Lakoff and Johnson detailed, metaphor is an important means of epistemologically organizing the world (1980). Orientational metaphors, which organize a system of concepts in terms of another and are grounded in experience, are particularly applicable here as a means of constructing subjective experience (Ibid.: 20). Deborah Lupton also noted that “[t]he frequent use of metaphor in the medical context is not surprising, for metaphor is used in all areas of verbal communication as an epistemological device, serving to conceptualize the world, define notions of reality and construct subjectivity” (1994: 55).

Amputees are remarkably inventive in creating their own metaphors to describe the fit and feel of prostheses. The prosthetics school employs amputees as “professional patients” for the students to practice patient management and casting, fabricating, and fitting prostheses. The students go through a ritualized critique at the conclusion of each practice prosthesis in which their patient demonstrates the use of the limb made for them (walking back and forth between parallel bars, for instance) and the faculty pose questions to the student about their choices and to the patient about their degree of satisfaction with the limb. On one occasion, a young African-American patient gave a running commentary on the practice prosthesis his student had made for him. As he paced back and forth between the parallel bars during the critique, he described why he didn’t like the prosthesis. “It’s like forks, you know? My normal leg, it’s like a silver fork. It’s solid. It’s strong, sturdy, you can really feel it when you pick it up. But this thing,” he waved dismissively, “just feels like a plastic fork. Like it might snap in half if I walked too hard on it.” He went on to explain that he preferred his heavier, exoskeletal leg because he worked in construction and needed a sturdier leg than the lightweight, endoskeletal leg his student had made for him. When he was done with his critique, Evan, the senior instructor, took the opportunity to point out the importance of occupation (and implicitly, class) as a consideration for prosthesis design. Amputees in physically taxing jobs will more likely than not require a heavier-duty prosthesis.

Longer-term amputees also share a few stock metaphors with prosthetists, who reproduce them in prosthetics school and clinic and use them to open communication with new amputees. Some of these, such as the ones Sean and I used, make use of our common, intuitive experience of walking on sloped terrain. For example, the feeling of walking into a hole feels like walking down a steep hill, your weight heavily on your heel and your foot quickly slapping down as your weight shifts to your other foot. Prosthetists understand this in terms of excessive dorsiflexion of the foot. Walking up a hill feels like walking up a steep slope, light on your heel, but spending a lot of time on your toes and actively pushing yourself off as you roll over your toes. This corresponds to excessive plantarflexion of the foot for prosthetists, who translate the metaphors into biomechanical problems and solutions. Metaphors of terrain are interesting because the floor of the clinic is obviously not sloped, but the alignment of the foot embodies an adjustable landscape in which the desired outcome is flat, almost as if the clinic floor is made level through alignment.

Other metaphors describe prostheses in terms of parts of the body, and both prosthetists and amputees often speak of prosthetic feet, for instance, as variously having toe, or not having enough toe, or as having a soft or stiff heel or toe. And during alignment, toes can also be turned in or out too far, giving the odd sensation of rolling over a foot which isn’t pointing in the right direction. At the prosthetics school where I field worked, students were assigned to work with professional patients and were given a wide variety of feet in order to get diverse opinions from the patients during critique. One of the patients was trying a brand of foot called Flex-Foot for the first time. The Flex-Foot is renowned for its springy quality because it is basically designed as a spring of carbon fiber. He commented that he liked the foot because “it has toes,” but these preferences are relative to the person using the component Brian, an engineering student at the lab and a bilateral above-knee amputee himself, didn’t like the same brand of foot because he felt they had “too much toe” and made it difficult for him to roll over the feet body part metaphors are interesting because prosthetic feet often do not actually have any internal structure corresponding to heels or toes, and these metaphors are indicative of how prostheses are embodied as common ground in both subjective and objective descriptions.

The ultimate metaphor for many new amputees is their previous organic limb, particularly as it enabled them at a younger age. Lance, one of Sean’s patients, often compared his prosthesis to his organic leg, but differentiated between cosmesis and feeling. He and his wife seemed happy that his prosthesis had a remarkable resemblance to his organic leg, but he had difficulty adjusting to it partly because it didn’t feel like his old leg. A variant on these metaphors for longer-term amputees is that they compare their new prosthesis to how their last one felt and looked. Amputees become strongly habituated to their prostheses, particularly to the fit and the style of suspension. This is an important issue for many older men who lost limbs during World War II and the Korean War and who still prefer the style of limb they started wearing in the 1940s or ’50s. Both of these metaphors put prosthetists in somewhat of a bind, since they can’t adequately replace an organic limb, nor can they exactly recreate the fit of another prosthesis.

These embodied memories of previous limbs, organic or prosthetic, are powerful because “[t]he body remembers” (Becker 1997: 193). In her ethnography of life disruption and continuity in America, Gay Becker discusses the role of narrative and metaphor as media for communicating bodily experiences of disruption and notes that “we carry our histories with us into the present through our bodies. The past is ’sedimented’ in the body; that is, it is embodied” (Ibid.: 12). Amputees’ histories of their bodies and bodily reconstructions become a medium for communicating their subjective experiences of their bodies and prostheses to their prosthetist. Becker argues that Americans give primacy to these body memories in managing life disruptions and preserving the illusion of continuity, two staples of our culture. This is a compelling argument for new amputees, whose embodied memories become a powerful metaphor for communicating their bodily experience of their prosthesis to their prosthetist and in adjusting to their new bodily configuration. It may be less applicable to longer-term amputees, who have likely normalized amputation rather than continuing to view it as a disruption in need of management.

Although Lakoff and Johnson do well to emphasize the experiential basis of metaphor as important, their structuralist approach neglects the question of culture. They argue that “metaphor is not just a matter of language,” but that “human thought processes are largely metaphorical.” (1980: 6) This suggests that we are more or less hardwired with metaphor, which we then draw upon to make sense of our experiences, which are a priori cultural, rather than constituted by culture. Other scholars have since further developed the concept of embodied metaphor in various forms to address cultural, as well as experiential, bases for metaphors (Becker 1997; Farnell 1996; Low 1994). Low looks to embodied metaphors of nervios as a way to problematize the clinical reclamation of suffering as symptoms (1994). Low cites Lakoff’s continued position that metaphor is grounded in the pre-cultural body and produces categories of experience (Lakoff 1987), as well as a critique Naomi Smith made of Lakoff and Johnson, suggesting that metaphor is culturally produced (Smith 1987) and embodied. Low accepts both positions, rendering metaphor as an “expression of lived experience that can communicate bodily sensation, as well as social, cultural and political meaning” (1994: 143) Low argues that bodily experiences mediate the relationship between self and society.

This bridge between experience and medicalization suggests an alternative to “[t]he limits of the univocal technoscientific interpretation of the medical domain” (Redding 1995: 99). In an article on patient compliance and management of diabetes, Ferzacca shows how men with diabetes use “regulated improvisations” to manage their disease (2000). He found that Foucaultian critiques of clinical interactions did not fully account for the practices he observed. Although biopower was undeniably important to clinical interactions, it did not account for patient self-management or interactions with staff. Attention to either the sick person’s expression of illness or to the physician’s domination of their patient neglects the mechanics and negotiation of treatment. Somewhere in between the narrative of experience and domination of the body, people get well. The problem for anthropologists, then, is how to model or account for this communication about bodies and medicine in terms other than interpretive versus critical.

Notes

1 This may not represent a shift at all for traditional clinical medical anthropology, but represents a recent change in thinking among health care educators and professionals.

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