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After a breakfast of Tvorozhniki [soft, sweet, cheese pancakes] with sour cream and fresh fruit, accompanied, of course, by tall glasses of strong tea from the samovar, we adjourned briefly to the library ro discuss our mysterious adventure of the night before. Dr. Boris smiled as he said "The cloak-and-dagger charade of our being brought to the palace in a closed carriage with the curtains drawn to a sickroom in the charge of a masked nobleman was performed mainly to impress us, you especially, with the importance of respecting the patient's anonymity. Both "Master V.M." and the masked nobleman are known to me at sight, and the latter by his voice, as well."Master V.M." is Prince Vadim Milanovski and the masked man is his uncle and guardian, Count Alexander Milanovski. The uncle's guardianship will continue until the Prince attains his majority in three years. Though Prince Vadim will retain the title of Prince and be addressed as "Your Highness", now that he is an eunuch, his father's estate and other titles will descend to his younger brother, Prince Semyon, whose guardian Count Alexander also is. If Prince Vadim had had no brother, he could not have been castrated and it would have been necessary for him to be married to some unfortunate young noblewoman, doubtless a close cousin, to beget an heir to the title. The parents of the two princes are first cousins and their paternal grandparents are first cousins, though their maternal grandparents, Prince and Princess Krensky are second cousins. I mentioned that the nobility are very inbred, and this is a classic example. I have no doubt that some members of the next generation of Milanovskis will be idiots.Prince Semyon is not exactly a shining light intellectually, not quite a moron, but a feather-brained buffoon. It is not surprising, therefore that satyriasis is among the common aberrations of the young noblemen. You will have many opportunities to treat it. Some of these young men have no brothers and their reproductive capabilities must not be destroyed. Obviously, this poses a problem. A problem for which I believe that I have found a solution I have come to realize that satyriasis is basically not a mental disorder; it is a disease of the testicles. There is no stigma attached to the need to void the bowels or the bladder (though excessive delicacy about the latter need led Pyotr Belicki [Peter the Great] to delay so long in emptying his bladder that it bursted, causing his untimely death.) Yet few persons (and NO women) recognize that the need of a man to void excess spermatozoa from his testicles and vesiculæ seminales is just as natural and just as pressing. The furor sexualis is an expression of the urgency of the need of a man to void semen. The difficulty of discontinuing the practise of excessive masturbation arises from the fact that the masturbator has accustomed his testicles to producing an abnormal quantity of semen which must, thenceforth, be got rid of. The same condition exists in the testicles of a satyr. This much was clear to me years ago. What I could not understand was the ætilogy of this pathologic condition. Why do the testicles produce a great excess of semen from time to time, causing an abnormal urgency to dispose of it ? I believe that I now understand this. The human nervous system is closely analogous to a telegraph system. Messages are exchanged between the sensory organs, the endocrine glands, the viscera, and the brain. When the testicles and seminal vesicles are congested, an urgent message is sent to the brain to relieve the congestion. This manifests itself as lust. If, on the other hand, the brain is stimulated to lust by the sight of a sexually desirable person, a message is sent to the generative organs to prepare them for sexual activity. The membrum virile becomes erect, but also, the testicles are stimulated to greater activity, more rapid and greater secretion of semen. All of this is quite normal. There are little-understood control mechanisms, some sort of checks and balances which usually prevent either lust or the secretory activity of the testicles from going out of control.In satyriasis, this control mechanism fails and the activity of the testicles runs wild. Now, if the telegraphic connexion between the testicles and the brain were to be interrupted, the testicles would continue to secrete sperm but not respond to any demands from the brain for more. Nor would the brain respond to messages from the testicles demanding that accumulated sperm be voided immediately. Eventually, the stored semen would overflow during sleep as it often does in healthy youths and men. Resection of the nerves within the spermatic cords ought not to have any adverse effect upon the testicles but would interrupt the exchange of messages between them and the brain. This is a much more delicate and difficult operation than resection of the pudendal nerve or of the erectile nerves which you have probably performed occasionally. The nerve fibres within the spermatic cords are much finer and more difficult to locate than those of the membrum virile. I have attempted this operation only once and found that I cannot see these fine nerve fibres owing to the degeneration of my retinæ. However, I am sure that the operation is possible and it is my hope that you will be able to perform it." I replied "Dr. Boris, I think that your theory is brilliant. I am certain that you have hit upon the true cause of satyriasis and devised the cure. Do you suppose that it could be arranged for me to attempt this operation on cadavers at the Imperial Medical School ?" "I am sure that it could be arranged, but why not experiment on a living patient whose family has authorized his castration, if necessary ? If the attempt should fail, you could proceed to castration. The patient would be no worse off than if he had merely been castrated without attempting the resection." "Yes, I could do that, and it has the advantage that I could follow the effects of the operation upon the patient over a period of time. It's obviously impossible to determine the long-range effects of treatment upon a cadaver !" Inasmuch as the same operation should be effective in the treatment of excessive masturbation as well, I could try it in such cases instead of waiting for another case of satyriasis (though Dr. Boris assured me that I would NOT have long to wait.) Our first case that morning, however, was that of a young man who came in wrapped in a great-coat even though the day was warm. I had seen that before and so had Dr. Boris. He smiled and whispered to me "Priapismus" "Jawohl", I replied. The unfortunate young man's phallus, both in colour and in dimensions, resembled that of a stallion. It was clear that much of the venous blood had clotted and that there was serious danger of mortification and septicæmia. As his command of German was inadequae, I was forced to have Dr. Boris interpret for me . I asked the young man how long his member had been in that condition, and he replied that he had awakened in that state some six hours ago and had attempted to relieve the erection by masturbation and by cold applications. I told him that priapism is always an emergency and that he had wasted precious time so that permanent damage had been done to the organ. "There is a grave danger that the organ will have to be amputated or even extirpated, and, even if it can be saved, you will surely be impotent." Dr. Boris corroborated my prognosis The patient was horrified and dismayed to learn this. I shaved away the pubic hair , disinfected the skin with diluted carbolic acid, and made a transverse incision on the dorsal surface of the penis, near the base, through the skin and the fascia, exposing the artery and vein. I drew out as much as I could of the vein with a blunt hook and severed it. Venous blood of the viscosity of honey oozed slowly from the distal portion of the vein. It was obvious that the only way that I could hope to expel the clotted blood from the corpora cavernosa would be to squeeze them, starting at the corpus spongiosum of the glans. Squeezing the corpora cavernosa, engorged as they were, would surely rupture the septa, thus obliterating the internal structure of the corpora cavernosa and causing irreversible impotence Nonetheless, I squeezed them and expressed the clotted blod. I could feel the septa bursting as I did so. Finally, however, the nearly black venous blood began to take on a redder hue and, by the time I had reached the incision, red, almost arterial-looking blood was being expressed. I stitched the severed sections of the vein together and inserted a thermometer into the urethra to determine if normal circulation had been re-established.It had, and I was able to stitch the fascia and the skin. The operation was technically successful, though the patient would always be impotent. The only other case of importance that day involved the castration of a sodomitic pæderast of 16, brought to us by his disgusted father. I strongly urged that resection of the pudendal nerve be performed as well to render him immediately harmless to little boys. His father agreed to this and the operation was essentially routine. Three days later, in the early afternoon, another disguised carriage came to the door, and a masked nobleman (I could tell by his bearing.), cloaked and booted almost like a highwayman, demanded our presence to treat a young man suffering from satyriasis. This was the case I had been waiting for. We were brought to the servants' entrance of a palace and by a complicated roundabout route to a bedroom where a wild young man of, perhaps, 20 was tied to a bed. He was screaming and shouting in Russian. Dr. Boris explained to me in German that the young man wanted a boy desparately and was especially exasperated that he could not reach his erect member in order to masturbate. Once again, Dr. Boris explained to the nobleman that I spoke only English and "Nemetz" . This nobleman had some command of English which simplified things for me greatly. The disguised nobleman explained that the patient was the only son of a noble family and must beget an heir. I asked if he had any interest at all in females and was assured that, though he found it distasteful, he could couple with a woman, so, his procreative power must NOT be impaired. Dr. Boris explained to the masked nobleman that there was an experimental operation which might cure the young man's satyriasis, but, that if it failed, it would be difficult to save his testicles. "Difficult ?" snapped the nobleman. "You are being paid to do what is difficult. Only, DO NOT FAIL !" The room had a southern exposure and I had the bed moved as close as possible to the largest southern window from which I insisted that all curtains be removed. As it was only slightly after 2:00 PM, the light was excellent. I strove to remember from my dissection of the spermatic cords of cadavers at Heidelberg, just where the nerves were located. I had had no occasion to use this information either at St. Marylebone Infirmary or in practise with Dr. Sir Roderick Hopkins who was concerned only with castration and phallectomy. I decided against severing the entire tunica vaginalis around the spermatic cord because suturing it together again carried much too much risk of inpairing the circulation to the testes, or of severing or damaging the vas deferens. This left me no alternative to opening the tunica with a fairly long longitudinal incision and fishing about in it with a blunt hook to locate the nerves.Though I had long ago memorized their names, the nerves did not bear tags or labels and I would have no way of identifying which was which. I must resect all of them and hope that the testicles would work without them. I was fairly sure that the only harm done would be to paralyse the cremasteric muscles and render the testicles insensitive to pain. Although I often disinfect my surgical instruments with carbolic acid, this time I demanded that they be boiled for fifteen minutes. I washed the scrotum with a harsh lye-soap, which though it irritates the skin, CLEANS. I removed every trace of hair from the pubes, scrotum, and thighs near the operation site. I disinfected the entire area with an alcoholic tincture of carbolic acid. I have been ridiculed both before and since then for my fanatical insistence upon cleanliness, but I have found that it greatly reduces the danger of inflammation. Dr. Boris assured the nobleman that I knew what I was doing.He still looked dubious. Just before operating, I asked for a powerful reading-glass which was brought and which I cleaned with alcohol. The patient was calmed with laudanum and I began. Many surgeons pride themselves upon operating at breakneck speed to reduce the amount of bleeding. If a limb is to be amputated, there is no alternative. It reduces the patient's suffering and reduces the loss of blood. In delicate surgery such as the resection of nerves, one must operate slowly and meticulously. It was impossible to conceal the fact that, in this operation, Dr. Bulgarin was assisting me. He held the reading glass and passed me my instruments. As I exposed the interior of the left spermatic cord, memories of dissections at Heidelberg came flooding back into my mind. I found that I didn't need to fish for the nerves, I KNEW where they were, and which they were. In some future operation , I would cut fewer of them, but this time, I was uncertain which "telegraph line" carried the messages which I must prevent from reaching the brain, so I resected all of them, removing about one inch of each nerve, by the usual procedure of twisting each nerve with the hook before cutting it. As expected the patient screamed when the sensory nerves were resected.. I exercised the utmost care in suturing the tunica vaginalis of each cord, to avoid damaging any of the ducts and blood vessels. By the time I closed the incisions in the scrotum, the sun had set. I was exhausted. Now, only time would tell if Dr. Boris' theory was valid and if the operations, technically successful though they were, had accomplished their purpose. We never learned the identity of our patient. Neither did we ever hear from his family again. I presume, therefore, that the procedure was successful. Assuming so, I performed it many times while I remained in St. Petersburg. Finally, the Russian winters became unbearable to me and I regretfully sold my practise to a German surgeon named Heinz Preussmann to whom I taught Dr. Bulgarin's operation and the theory behind it. By this time Dr. Boris, my friend and mentor had passed away. I, however, shall never forget him. |