Larry the pimp

As nearly as anybody could tell, Larry was not much good at anything.  He lived on the streets of downtown St. Louis and through whatever he did he managed to avoid the welfare department.  If he ever had a penny to his name he spent that.  At six-foot-two when he was twenty five years old he developed sores on both feet that would not heal, and suffered from recurrent infections.  He may have been referred to the Medical Center because of his rare disorder or for the outstanding prosthetic program.  Some folks speculated he was sent to Columbia because all the free clinics and medical centers in St. Louis already knew him.

Obtaining a responsible work history from Larry was an exercise in futility.  In today’s terminology when you find a person who is vague about his work activities, he may refer to himself as an entrepreneur.  In that case, drug dealer or pimp is probably closer to the truth.  None of these folks ever pay income taxes as they can never be found, and they deal only in cash.  Druggies would likely capture most of them, whether or not they can afford the cost of a fix.  Yes!  Virginia.  I am dripping with sympathy for the poor and down-trodden.  Pimp is easier to spell than entrepreneur.

As pathetic as Larry appeared, he also suffered from a rare and pathetic impairment, a complete lack of sensation in both legs.  The disorder flagged on his chart was congenital sensory radiculoneuropathy.  His muscles worked fine, but he could not feel pain, cold, hot, injury, broken, sore, or other sensations.  He walked because of muscle memory (?), not because of any sensory feedback about where his feet and legs were positioned in the world.  He was like the paraplegic who propped his feet on the pot-belly stove when it was hot.  He did not know he was in trouble until he smelled burning flesh.  It was his own flesh.  Then it was too late.  Unlike most paraplegics, Larry never knew any difference, as he was born with this impairment, and never experienced any loss of function.

It was also evident that Larry’s muscle memory was superior to the memory he demonstrated between his ears.  In the name of serving a statewide, compassionate indigent medical facility, the treasury was open for business.

The prevailing medical opinion was that Larry would suffer recurrent infections until eventually he would die from infections and related complications.  To remedy this circumstance the offending structures were to be amputated, both feet and legs well below the knee.  He was then to be fit with artificial legs in which primary weight bearing would be handled by the patella tendon, the tough and very durable tendon below the knee cap.

While it was accepted that this was a high risk patient with limited ability to respond to early signs of trouble, the hope was that he could return to nightly strolls along the streets of St. Louis inner-city, and resume whatever activity he was engaged in before his amputations.

With our incomparable prosthetic program, Larry was fit with two below-knee artificial legs shortly after surgical removal. With physical therapy directed at gait training he was able to pick-up his hulk and walk with the assistance of two forearm crutches.  With almost complete ability for self-care, he was returned to his old haunt in the St. Louis Bowery.

For many weeks the medical community heard little or nothing from Larry.  Then the inevitable message was received from folks in St. Louis.  Larry was in serious need of major modifications to his new legs.  He was transported back to Columbia by ambulance and admitted through the emergency room entrance.

Larry was unable or unwilling to follow the very explicit instructions given about stump hygiene.  When not wearing the artificial legs he was to keep the stumps appropriately wrapped to prevent any swelling.  This is a painless procedure, and in Larry’s case it was always completely painless.  Larry was completely painless throughout both legs regardless of what he did.  Pain, as a protective mechanism, did not exist for Larry, whose nearest pain receptors were much higher up.

When he arrived in Columbia the bones had protruded through the bottom of both stumps, while Larry appeared almost indifferent to the grotesque scene.  Larry had worn the legs considerably, but had failed to maintain adequate stump hygiene through washing and wrapping when not in use.   As a result he was bearing his rather substantial weight around the flesh of each stump, rather than on the patella tendon.  A most marvelous alteration was needed to fabricate artificial limbs that were, in Larry’s case, completely fool-proof.

A partial solution was at hand, but required the treasury to remain open a bit longer.  Actual weight bearing must be built into his legs at a point where he could feel pain when things went wrong.  Minor modifications were made at the site of each amputation, the stumps, which were repaired and healed nicely under sanitary conditions.  It was determined that some actual pain receptors were located where Larry sits.  As it happens this is the primary site for weight bearing for folks with amputations above the knee.  These folks bear weight when standing as though they are sitting all the time.

Two form fitting, weight bearing, plastic laminated sockets were tailored to Larry’s torso.  These sockets were attached through bilateral, stainless steel braces and knee joints to two brand new artificial legs.  These new legs transferred weight from each stump to his inferior pelvic bone on each side so he could stand and walk using his knees for mobility.  The hope was that they would produce pain when he had stood too long.  There was, unfortunately, no good remedy to improve his general hygiene, keep his stumps wrapped when not in use, and otherwise maintain a reasonable level of cleanliness.

The additional sockets and stainless steel braces added another ten pounds to each artificial leg, and increased the difficulty in putting the contraptions on each day.  Following complete reruns on hygiene, stump wrapping, and gait training, Larry was again ambulatory, and was deemed fit to return to his old haunts in St. Louis.

One sidelight followed this second attempt to keep Larry ambulatory.  Combining the emaciated stumps with certain principles of physics and medical necessity, the bones in Larry’s stumps were shortened as much as physics and two below-knee artificial legs would allow.  Obtaining a sufficient covering of flesh was essential to renovate and heal both stumps.  Larry returned to St. Louis about three inches shorter than when he had left.  Whether this particular alteration was noticed by any of his friends is not known.  It is very likely that Larry never knew the difference.  What is the loss of three inches, more or less, to a pimp?

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