Finger Frostbite Amputation Photographs

I lived on the street for twenty-five years and never had a serious health issue, even though I slept outdoors under a tarp through every imaginable weather.  But, I got caught in a canyon downslope wind storm that resembled wind storms recorded in the death zone on K2.*  My hands turned blue, but I thought if I warmed them up, they would recover.  Next morning I had blisters, I thought I had second-degree frostbite.  Instead of recovering from a moderate frostbite, my hands died from blood clots.  Apparently, the body will reduce the blood flow to the extremities in order to protect the vital organs in the core during life-threatening wind chill events.  I should have gone straight to the hospital.  Maybe Dr. Amalia Cochran could have saved my digits.  After all, Dr. Amalia Cochran pioneered the use of blood thinners in severe frostbite cases to save fingers and toes with remarkable success rates.  I was blessed with one of the best frostbite experts in the country as my doctor, and all she could do was cut off all of my fingers.

The dynamic duo.

Amalia Cochran MD 

Katherine Elizabeth Smiley MD

If you need an excellent surgeon, (or two) look no further than this blog post.  Fortunately for me, both of these accomplished ladies were working together at the University of Utah hospital intensive care burn unit.

This is no longer the case, however.  Dr. Cochran is now off to Bozeman, Montana!   Dr. Smiley has a private practice as an allopathic trauma surgeon in Bloomington, Indiana.

Ha!  Look at your flowery hat, Amalia!  But because I am a sixties counterculture guy, you can wear tye-dye day glow in surgery for all I care!  I don't place a priority on being a misogynist when facing certain death.  I can't understand gifted feminists and their persecution complexes.

I don't think these ladies are iron maidens who have to maintain a facade of inflexible super-rationality because some idiot invented a notion that women go mad every twenty-eight days.  Therefore, women can't be trusted with the nuclear football.  But we don't live in the world of Betty Friedan and the Feminine Mystique, or in the world of Father Knows Best anymore.  1950's retro thinking is so cliche.  I was so thankful for these women surgeons, and for my free clinic doctor Tanya Williams MD who got me admitted into the hospital.  Superior intelligence, skills, and empathy.  Who cares what sex they are, or what they wear at work.

I needed great surgeons, not a militant Gloria Steinem manning the barricades.  I was lucky to receive such awesome care at the University of Utah burn center.  Amalia Cochran is a universally recognized expert in frostbite, with a slew of medical journal publications. And Dr. Amalia Cochran has published a book on introductory surgery.  Dr. Kate Smiley graduated from medical school with honors! and she has a very successful practice that is based upon a diversity of medical experiences!

I may be thick, but I know good health care professionals when I see them.


* When the Wasatch mountains experience conditions that generate easterly winds, gravity straight line winds may occur with speeds exceeding 100mph.  These straight line winds historically have caused considerable personal and property damage.

Post Traumatic Stress Disorder: Random Thoughts

Living a life of chronic pain is something I never imagined.  One becomes hyper-aware of environmental inputs to the point of morbid intensity.  The stress is unendurable.  The realization that this condition will never improve inspires fatalistic thoughts and deranged conjectures.   For example, when I die will I awake in some religious purgatory with this infernal misery as punishment.  I was indoctrinated as a child and have lasting scars.

I understand the reasoning of our wounded warriors who return from a valorous fight maimed for life and who have been changed forever.  I empathize with these brave patriots who after experiencing unimaginable trauma, can no longer maintain their former personalities.  Brave soldiers who have become so physically and mentally dysfunctional they no longer fit properly in the context of our society, or in the context of their own families.  This may explain the huge number of homeless veterans who sleep on American streets daily, forsaken and cast aside by the most giving of all nations.  This abandonment of our veterans is a national disgrace.

I knew homeless veterans personally, not as a detached social worker, but as a homeless bum.  Our group did not drink alcohol or use drugs.  We did not fly signs, pester people for handouts, receive food stamps, or receive cash assistance.  Some of my old friends were pensioners who actually contributed years of work to society.  Yet these gentlemen preferred to dine at soup kitchens and live under tarps under trees through every type of imaginable weather, exposed, harassed, fearful, hungry, dirty, and insane.  Why am I telling you this?  Stereotypes, as conceived from afar by ivory tower talking heads, don't apply to everyone who lives on the street.  They are not all lazy people either.  Some take day jobs desperately wanting to escape their plight.  The rent-a-bum industry makes a fortune off of down and out hard luck people.  Some even gain long term employment through temporary services, but most aimlessly drift from job to job, from town to town, accomplishing nothing.

When I was in the University of Utah burn unit (costing the taxpayers God knows how many thousands of dollars) I asked to be released before the doctor even considered it.  I had nowhere to go except for the shelter medical bed.  When I was being discharged from the hospital I had a chance encounter with a homeless liaison social worker.  She shamelessly shouted at me in the hallway from afar, that I could not continue to mooch off the hospital forever.  I was never so offended in my life.  Did she think that I was using the hospital as a sort of vacation retreat and that the hospital staff had to force me from my bed?  If that cunt had expended five minutes of her time familiarizing herself with "my case" she would have never been so rude and insulting.  Social workers have no business among poor people.  Her behavior typifies the prevailing response you can expect from these social justice warriors who claim to have a monopoly on compassion for the sick and injured in this world.  Snide condescending jeers and sneers.  Mangled veterans suffering from post-traumatic stress disorder probably run the same gauntlet when dealing with professional psychiatrists who consult their diagnostic manuals, and like pontificating gods, espouse factitious disorder or malingering.  Meanwhile, people are left to dangle in the wind to deal with a constellation of mental horrors alone and unaided.  Have no doubt, people derive a great deal of sadistic satisfaction from the misery of other people.  But when the laughter subsides, when fatigue of supporting a chronically debilitated person takes over, people do get bored with the plight of disability and frustrated being around people who cannot control their moods and who involuntarily express discomfort, sometimes irrationally.  I have been guilty of irrationality on many occasions.  This has lowered my self-esteem, damaged my interpersonal relationships with family members, and has filled me with remorse.

There is a distinction, however.  I am entirely responsible for my folly.  I had a choice to behave like a fool.  I was not serving my country as a loyal patriot.  I was not ordered into battle.  I deserve my misery.  I understand that some injuries change people forever.  I understand why so many people consider suicide.  The country can do better to help people who are not at fault and who served with distinction.

I used to spend days in the library researching depression.  I thought I had rewired my neurons, a firm believer in plasticity.  That was a voluntary effort, but this chronic pain is beyond conscious control due to the sheer number of damaged pain receptors in my bones and skin.  Extinction is impossible.  Recently, I have been fighting suicidal ideation.  There is a concept in psychology known as learned helplessness.  A rat is placed on an electric grid and shocked.  No matter what kind of behavior the rat engages in, it cannot escape the shock.  There is no avoidance response to learn.  So the rat cowers in the corner doing nothing.  The rat has an instinct to survive, but the rat has no language skills to communicate the trauma the rat is experiencing.  Human beings have the ability to conceptualize uncontrollable suffering, even rate pain intensity on a theoretical scale, but there are limited behavioral strategies available to reduce the perceived stimulus.  There are certain pharmaceutical interdiction available, opioid or anticonvulsant remedies, that can be ingested to reduce chronic pain.  Drugs could be considered a behavioral strategy, which produces fleeting medical efficacy.  The effect of pharmaceutical interventions is temporary and implies negative secondary psychoactive side-effects such as increased suicidal ideation.  Pharmaceutical behavior designed to reduce pain is directly contravened with increases in distorted perceptual sensory input; into the association cortex, pre-frontal cortex, and limbic systems; the centers of long term memory assimilation, executive planning, conceptual thought, and emotion.  Gabapentin causes mood swings, and has a high suicide incident rate.  Opioid derivatives have high overdose rates.

Pharmaceutical interventions have a transitory effect, high tolerance, and short half-lives.  Dependency on pharmaceutical drugs becomes a huge problem.  Delta-9-tetrahydrocannabinol (THC), the psycoactive component of cannabis, and similar holistic remedies have theoretical pain relieving medicinal properties.  However, delta-9-tetrahydrocannabinol (THC) is a hallucinogen that fits into the cannabinoid receptor active sites within the brain.*  Delta-9-tetrahydrocannabinol (THC) like opioid compounds alter perceptual awareness, creating transitory euphoric effects.  Endorphins and enkephalins can be theoretically generated by and reinforce euphoria.  Endorphins and enkephalins may be referred to as endogenous opioids.  But altered perceptual awareness is no panacea.  Chronic pain though suppressed below threshold briefly, always returns to remind you that the situation is hopeless.

It is inhumane to force people to suffer, but millions do every day without any possible respite.  We as a nation can do better to help those who cannot help themselves.

A physiological experiment worthy of Sigmund Freud

*I have considered experimenting with delta-9-tetrahydrocannabinol (THC) like the intrepid researchers of yore, to find out if medical marijuana is real or a hoax.  But I don't want to sit around like a stoned zombie all day long.  And I can't stand the stink of Mexican skunk weed.  But there are synthetic variations of THC, dronabinol or marinol, that would be very effective research tools sans the stink.  I have talked to people who smoke marijuana and have asked for their opinions on the painkiller properties of marijuana.  One person said marijuana alters pain awareness, you feel pain, but don't care.  This indifference to pain, under the influence of cannabis, intrigues me. Maybe, even though the brain percieves pain, the brain through some unknown mechanism considers the pain a trivial concern.  Maybe, the solution to the problem can be found in trait-state pain perceptual thresholds.  The pain threshold in the trait mode has value x.  Pain threshold in the stoned state mode has value y.  This idea is most intriguing as a hypothetical construct and should be explored scientifically in controlled experimentation.  However, formulating a measurement tool for threshold would be a daunting task, as all responses to be measured would be subjective opinions of the person being measured.  But pain is measured by opinion now.  Walk into a clinic or hospital and notice the row of cartoon faces.  The faces change from happy to angry, each face is assigned a number.  Zero is assigned a happy face with a broad smile, indicating little pain.  Ten is assigned to a angry frowning face, indicating severe pain.  You ask the person sober to indicate a face that reflects his opinion of his or her pain at the moment.  Then after taking a dose of marinol you repeat the question, which face represents your current opinion of the pain you are experiencing at the moment?  Then measure the difference.  Crude, primitive, unreliable, with very little validity, but what else is there?  You might increase the dose of marinol, or reduce the dose of marinol, or vary the time scale, or monkey around with a million other variables until you establish some approximation to scientific truth.

Controlled medical experimentation is a much better idea than relying upon the hysterical debate of people who are either in favor of, or against, the notion of medical marijuana use.

Eugene Onegin: Alexander Pushkin

Dover Publications 

Eugene Onegin is an epic poem written by Russian poet Alexander Sergeyevich Pushkin.  The poem published in 1833 profoundly depicts Russian culture of that period.  Eugene Onegin is considered by Russian literary scholars as the first epic poem written in the Russian language since The Lay of the Host of Igor, (1185).*  Eugene Onegin served as a template for future Russian literary works.  In 1833 books written in Russian were rare, or of poor quality, or the product of the sentimentalists.  Suddenly, Russian genius blossomed.  Nikolai Vasilievich Gogol wrote, The Inspector General, (1836) a classic Russian comedy and play.  The plot of The Inspector General was originally suggested to Nikolai Gogol by Alexander Pushkin.  Mikhail Yuryevich Lermontov, a great Russian poet, wrote the prose classic,  A Hero Of Our Time, (1839).  Ironically, Alexander Pushkin and Mikhail Lermontov were both killed in duels, although Mikhail Lermontov was allegedly shot in the back by a solider with a carbine rifle, during the duel, under the direct orders of Czar Nicholas.  Czar Nicholas was a particularly spiteful man who crushed the Decembrists, exiled Alexander Pushkin, murdered Mikhail Lermontov, and exiled Fyodor Dostoevsky to Siberia.  Nevertheless, in spite of the heavy handed censorship, the 1830 publications would spawn the Russian literary Rennisance, which reigned supreme until the Boleshivek revolution reduced Russian letters to petty partisan formulaic gibberish.  After the publication of Eugene Onegin, during the Rennisance, the Russian people would be blessed to read and enjoy literary classics written in Russian.  Everything from romance to the seminarists.  The years of literature imported from Europe, and read mostly by aristocratic families, had come to an end.

N.B.  French, the universal language, was taught to children by tutors in wealthy Russian homes.  Speaking French coveyed aristocratic status upon the speaker.  Alexander Pushkin spoke, read, and thought in French, not in Russian.  Eugene Onegin changed the Russian literary landscape forever.  Simply put, Alexander Pushkin wrote a poetic masterpiece in the neglected Russian language.  Alexander Pushkin demolished the idea that Russian language and culture was barbaric and offered no artistic merit.  Alexander Pushkin is a genius of the first order.  Alexander Pushkin is the greatest Russian poet, and one of the greatest revolutionary thinkers Russia has ever produced.

Eugene Onegin is a story of a young girl, Tatyana, who is passionately in love with young rake Eugene.  Eugene has inherited a country estate from his uncle; a man whom Eugene despised; adjacent to Tatyana's ancestral village.  Eugene is a man notable for treading upon theatre patrons feet with crass indifference.  Eugene has a remarkable tendency to offend people with a cavalier swagger.  Eugene is a misanthrope; a precursor to the superfluous man; a wealthy landowner without any purpose in life, who is imprisoned by social convention, and who is unable to make any meaningful contribution to society.  This lack of social graces will prompt Eugene to make callous decisions that will chart the decision-making process of Tatyana after she has matured into a sophisticated societal married woman and is forced to make a choice.  Tatyana is stifled in a world of social ennui, but when forced to choose she refuses to abandon her husband for Eugene who is now passionately in love with her.

Tatyana is a young woman trapped on a landed estate in rural Russia before the emancipation of the serfs.  Russia during this time was a highly stratified society with classes of people ranging from landed serfs to aristocratic gentlemen.  Social mobility between classes was impossible.  However, it was not uncommon for serf girls to become impregnated by landowners.  Pushkin fathered a child with a servant girl on his family estate while in exile.  Pushkin abandoned this girl, and when she died, he expressed in a poem no regret or interest in her or his child.  On rare occasions, a landowner would marry a serf girl.  But in most villages, the land owner's illegitimate children would live with the mother in poverty and would run about among the peasant children.  However, for women, standards were inflexible and exacting.  The slightest indiscretion could ruin the reputation of a young woman forever.  A young woman writing a young man an innocent love letter was expressly forbidden.  Public shaming of women accused of infidelity was not uncommon.  Smearing pitch on a gate post of a home of an accused woman would invite public community ridicule and shame her forever.  Even if the accusation had no basis in fact.

Tatyana faced a second problem.  Young Russian women above twenty-five years old were considered by frantic parents as destined spinsters.  Plus the availability of desirable suitors was limited by geography and class.

One fine day, Eugene agreed to accompany Lensky on a visit to the Larina household.  Lensky was enamored with Olga Larina, a silly, flighty girl.  Instantly, the family and community declared Eugene and older sister Tatyana Larina a perfect match.  Tatyana was under tremendous family and social pressure to find a husband.  Tatyana was willing to accept Eugene as a suitor.  But was Eugene willing to accept Tatyana?

Occasionally Eugene would accompany Lensky when he visited Olga.  Tatyana longed for these visits to see her imagined lover.  On one occasion, when Eugene and Lensky left her home, Tatyana spied upon Eugene from her bedroom window.  Tatyana passionately drew the initials E.O. in the frost on her windowpane.  Tatyana loved Eugene!

Tatyana was a wholesome Russian girl, superstitious, she would not have refrained from casting salt over her shoulder to ward off the evil eye.  She loved the outdoors and rustic life.  Tatyana was also an impulsive, impatient, headstrong girl.  When Eugene did not respond to her advances, Tatyana made a rash decision to send him a letter declaring her intention to serve as his faithful devoted wife, and she arranged a clandestine meeting with him in her family garden to discuss her proposition.

The letter and meeting were very dangerous for Tatyana if she were to be discovered.***

Before the meeting, Tatyana spent time in flights of fantasy, she would visit her favorite grove of trees and pick her favorite flowers.  On the night of the engagement, when Eugene arrived, Tatyana raced from her bedroom down the stairs to the garden to speak to her lover before anyone could intervene.  Eugene declined to offer Tatyana marriage, but Eugene did assure Tatyana he would extend her respectful "brotherly love." ****

Tatyana turned away from Eugene "in despair."

Vladimir Lensky was an idealist and a romantic with poetic aspirations.  In contrast to Eugene, Lensky loved social gatherings and life.  Lensky persuaded Eugene to attend a name day party for Tatyana, under the pretense there would be few guests.  However, when they arrived at Tatyana's residence, every landowner in the district was in attendance at a grand ball.  Eugene was extremely irritated by Lensky's ruse and vowed revenge.  Losing all restraint, the impetuous Eugene taunted Lensky by forcing Olga to dance with him all evening.  Lensky was so incensed he challenged Eugene to a duel. *****

Some may argue Eugene was a heartless beast who went to the duel with callous indifference as to the consequences of his actions.  I disagree.  I think Eugene did not care to fight and he would have found a plausible excuse to avoid the whole issue if it were not for the prompting of his second, Monsieur Guillot.  Monsieur Gulliot is portrayed poetically as a retired military officer, a confused busybody, incompetent opportunist, drunkard, and mountebank.  Eugene overslept, missing the scheduled rendezvous, and he would have probably dismissed the whole duel with ennui had not his second, Monsieur Guillot, arrived reminding him that he was late for the engagement.  When Eugene killed Lensky he was horrified at this senseless act.

The specter of Lensky would haunt Eugene forever.

Eugene disappeared.  He did not wish adieu to Tatyana, he simply ordered his carriage and horses one morning and vanished to parts unknown.  Tatyana was abandoned without a thought.  Alone and sorrowful Tatyana would take long walks until one day she arrived at Eugene's abandoned estate.  There she conversed with the old caretaker who out of sympathy allowed Tatyana to access Eugene's study and to peruse Eugene's books.  This was the pivotal moment for Tatyana.  Tatyana diligently studied the underlined passages and marginal notes in Eugene's books to discern Eugene's soul.  Also, the passage of time heals all wounds in love.  Separated from Eugene her ardor cooled.  Tatyana's feelings for Eugene had changed.  Tatyana now knew the true Eugene.  Tatyana saw her naive romantic idealism shatter like a pane of glass.******

After Eugene departed without a word after he killed Lensky in the duel, Tatyana stubbornly refused numerous proposals for her hand.  But for poor Tatyana times were changing.  Although Tatyana and Olga made numerous forays to Lensky's lonely grave to mourn Lensky shortly after the duel, over time memory fades and people are replaced.  Tatyana's bosom companion Olga soon forgot poetic Lensky.  Olga met and married a military man who was on assignment to a distant front.  After Olga left with her husband, Tatyana faced terrible loneliness.  Determined to do something, Tatyana's desperate mother decided to take Tatyana to Moscow to the matchmakers and marriage market.  Tatyana was placed in a sleigh, driven to Moscow, shopped among balls, and eventually, she married a "fat general".**  The idyllic lifestyle Tatyana had envisioned as a simple country housewife with Eugene had vanished forever.

Eugene traveled from one station to the next over countless versts for two years aimlessly wandering all over Russia.  But one fine day he appeared at a social ball in Moscow.  Victims of Eugene's old pranks were not happy to see him.  But who did Eugene see dressed like a queen in her resplendent glory?  A woman he had completely forgotten, Tatyana!  Worse she was married to a fat general!  When Eugene approached Tatyana she greeted him with majestic glacial reserve.

But instantly, Eugene fell madly in love with Tatyana!

The roles had been reversed.  Tatyana was now indifferent to Eugene.  When Eugene and Tatyana met by chance at receptions, Tatyana always met him with the same icy reserve.  Eugene was so disconcerted he went into seclusion, a veritable recluse, he retired to his study reading books round the clock as a diversion.  Did Eugene think Tatyana would thaw if he improved himself after a wasted youth of slothful dissipation? Eugene even penned two sincerely heartfelt letters to Tatyana.  But these letters were never acknowledged by Tatyana with a reply.  Nothing Eugene did improved his relationship with Tatyana.  Tatyana was as cold and reserved as ever.

Driven to despair, Eugene was unable to endure another moment without Tatyana.  Eugene threw down his book, ordered his coach and horses, and sped to Tatyana's home.  Stealthily passing Tatyana's housekeeping staff, Eugene clamored up the stairs and burst into Tatyana's room.  Tatyana was sitting on a chair sewing some lace.  Eugene fell upon his knees and declared if Tatyana would forgo the "fat general" and renounce her unhappy artificial repugnant social life, he would take her to his country estate, provide for her welfare, and remain loyal to her forever.  But Tatyana would not budge.  Tatyana woefully explained even though she still loved him, and even though she did honestly prefer the homespun lifestyle she outlined in her letter, nevertheless, she would continue to live her current loveless life no matter how stifling.

Tatyana was convinced if she separated from her husband Eugene would regard her as a conquest, a trophy, to be bragged about in jest to all his deplorable friends and rivals all over Moscow.  Tatyana simply did not trust Eugene.  Tatyana thought Eugene's protestations of love poor acting and insincere attempts to manipulate her under false pretenses.  Tatyana hated her husband and lifestyle but she would remain faithful all the same.

The "fat general"** makes an unexpected entry into the room ending the conversation.

Eugene and Tatyana are destined to live miserable lives forever apart.

Tatyana was wrong in her reasoning.  I believe Eugene had abandoned his nefarious life and he had grown weary of his nomadic wanderings.  Eugene did not return to Moscow by accident.  I also believe the death of Lensky weighed like an albatross around Eugene's neck.  The chance encounter with Tatyana gave Eugene a new sense of purpose in life.  Eugene regretted his stupidly squandered years of dissipated youth.

But the reconciliation was not to be.

Afterward

Alexander Pushkin had intended a sequel for Eugene Onegin.  But Alexander Pushkin was killed in a duel by Georges d'Anthes.  Georges d'Anthes allegedly sent Alexander Pushkin an anonymous letter "Certificate of a Cuckold" implying that the court historian, Alexander Pushkin, had been made a cuckold by Czar Nicholas.  There was abundant court rumor beautiful Natalia Pushkina and Czar Nicholas was entangled in a torrid affair.  The insulting anonymous taunting letter prompted Alexander Pushkin to arrange a duel with Georges d'Anthes on January 27, 1837.  The combatants approached each other in waist deep snow.  Alexander Pushkin was shot in the hip, but Alexander Pushkin managed to return fire, the slug grazed Georges d'Anthes hand and knocked him off his feet.  Despite the heroic effort of Konstantin Danzas, who performed on-site surgery, Alexander Pushkin died of infectious complications two days later.  Alexander Pushkin was thirty-seven years old.  It was reported that Alexander Pushkin from his sick bed looked at the books in his library and shouted: "goodbye old friends!"  Thus, the Eugene Onegin sequel was never written.  A great tragedy for Russia and world literature.

Footnotes

*Lays. Old Russian fables or songs were passed from father to son and recited or sung to audiences.  Many lays cited Russian heroes and heroines.  Many of these Russian heroes and heroines possessed supernatural powers.  The content of the lays would evolve over time with additions and subtractions.  For centuries, written language, except for a few clerics, was almost non-existent among the Russian people.  The Lay of the Host of Igor was the first lay to be written down on paper in a Slavic language.  Illustrations were added to the lay by cleric artists at unknown dates.  It is important to note that in 1840, out of a Russian population of ten million souls, only one hundred and fifty thousand people could read.  In certain aristocratic homes people could not speak or read Russian.  Tatyana, when composing her letter, struggles to master fluent Russian grammar.

**In Russian literature generals are often lampooned derisively as bombastic, uncouth clowns.

***This concept was beautifully conveyed in opera when Tatyana began to compose her letter.  She would write a line, stop in frustration, crumple up the sheet of paper, and toss it on the floor.  A peasant servant enters the room and begins to gather up the discarded drafts of the letter, oblivious of the contents, or of the danger to Tatyana.  The Peasant cannot read!  To the peasant, the discarded drafts are nothing but useless rubbish to be removed and thrown out.  The problem?  If Tatyana's mother or nefarious vindictive people who could read discovered these drafts by accident, Tatyana could face hysterical recriminations, blackmail, or tragic social censure.

****In the poem and opera, Tatyana accuses Eugene of rejecting her in the country because of her rural upbringing and demeanor, but because of her newly acquired social polish and wealth, Eugene changed his mind and is now willing to accept her.  Tatyana's bitter feelings are understandable, but her conclusion totally misses the point.  Eugene did not care if Olga, Tatyana, or Catherine the Great wrote the letter.  Eugene would have reacted to all of these women with the same aloof indifference.  Social status meant nothing to Eugene.  Eugene was so detached and jaded at the time from social anomie, he would have scoffed at the ardent desires of any woman without a pang of conscience, including the Czarina of Russia.  And totally forget her next day.  Eugene understood the tremendous pressure Tatyana was undergoing from her family to get married.  After all, the community had matched Eugene and Tatyana and a wedding announcement was expected soon.  Eugene demurred because he thought after attaining security, the good elements of marriage; love, beauty, would be replaced with self loathing and poisonous recriminations.  A harebrained opinion Tatyana would make Eugene dearly pay for.  But somewhere on the road, Eugene faced an existential crisis, thinking about the duel and Vladimir Lensky.  Eugene wanted some relief from his pointless social malaise.  A wife and family life suddenly seemed to be a better option than aimlessly wandering about Russia from one dirty station to the next.  Eugene offered to take Tatyana away from her pointless social suffering and he had the means to make her happy.  Tatyana refused because of the books she read, she did not understand the metamorphic change in Eugene.  Pushkin could have turned Eugene Onegin into Anna Karenina, the general could have refused to give Tatyana a divorce, and the poem could have devolved into a long psychological dissertation of Tatyana and the brutal Russian process of obtaining a divorce for a woman against the wishes of her husband.  But for Tatyana one intolerable situation would have been exchanged for another, with no net gain.  Or Tatyana could have said "yes" to Eugene, "and they lived happily ever after," which would have destroyed the purpose of the story.  Pushkin left the audience in agony over the fate of Eugene and Tatyana.  This is why Eugene Onegin, "a novel in verse" will be acted out in operatic plays forever.

*****Opera, as a time saving device, always has Lensky challenge Eugene to the duel during the ball in front of Tatyana and Olga.  But in the poem, Olga and Tatyana have no clue.  Lensky pays one last charming visit to Olga, while Tatyana spends a sleepless night jealously angry at Eugene.  Unexpected news of the death of Lensky would come as a complete surprise to both Olga and Tatyana.

******A Russian language professor once told me it is important to note that Tatyana read all of Eugene's books.  Tatyana was not satisfied with a casual examination of Eugene's soul.  Tatyana wanted to know everything about Eugene.  Tatyana was very disappointed with what she found.  Tatyana could not forgive Eugene for his amorphous indifference to life or for his callous disregard to her needs and interests.  Tatyana was furious Eugene abandoned her.  Tatyana wanted a husband who would take care of her, her children, and the village.  Tatyana did not want a detached absentee landowner who places the enterprise into the hands of a unscrupulous overseer who would ruthlessly savage the peasants and swindle Eugene out of revenue by under reporting crop yields.  Tatyana did not want to live with a dandified Oblomov in Moscow while the village decayed into dust.  I think Tatyana developed a psychological aversion to Eugene no amount of begging or pleading could rectify.  This may explain why Tatyana was so cold and unfeeling in Moscow, and why she rejected Eugene's entreaties point blank.