&•*.) The Preservation of the Hymen HOWARD A. KELLY, M.D. Baltimore BBPRINTBD FROM The American Journal of Obstetrics VoL XXXVII. No. 1,1898. NEW YORK WILLIAM WOOD & COMPANY, PUBLISHERS L3 « K .4 H V -UHSE^GCNEIL'S OFFICE DEC. 30.-1^01 'VT.JV •: THE PRESERVATION OF THE HYMEN. In Celsus' " De Medicina," ' written about the time of Christ, in the chapter on calculi, after declaring that small calculi may escape spontaneously through the shorter and more relaxed urethra, he says that in most cases it will be necessary to apply the same methods of hooking the calculus down and holding it against the neck of the bladder while incising, as in men, but he adds the caution that in the virgin the finger must be intro- duced per anum, as in the male, while in married women it may be introduced into the vagina. Severin Pineau, in his work written at the end of the six- teenth century on the signs of virginity, quotes the ancients as his authority for the dictum, "it is criminal to rupture the hymen" ("magnum est crimen perrumpere virginis hymen"). And such has been the attitude of the profession through all the centuries of the past; honorable men have ever carefully guarded as sacred the rights and the interests of the young women who have trusted their persons to their professional care, and the barrier which Nature has erected at the vaginal introitus as the sole prima facie evidence of virginity has been preserved, intact. I wish now to urge, in the first place, that it has remained for our day and generation, at a time when a study of the diseases of women has become a fashion, for practitioners of medicine to ruthlessly disregard all moral considerations and make digi- tal examinations of young women with pelvic pains at the menstrual period, or those presenting any abnormality in the menstrual flow or complaining of a leucorrhea. I know not how else to characterize this cacoethes exami- nandi, this reckless habit of investigating the sexual organs of young women, than as a species of rape. 1 "Sed in virgini subjici in anum digiti, tanquam masculo; mulieri, per naturale ejus debent." lAlltt.AkY ^UPGEONOCNefiAl'S OFFICE DCC.-30.-I Ml 2 KELLY: THE PRESERVATION OF THE HYMEN. I know, for example, of a large institution in our city en- trusted with the education of young women from all parts of the country. In numerous instances young girls with purely functional dysmenorrhea are taken to a physician, who exam- ines them, inserts specula, and institutes treatments where, as I have had occasion to verify, there is actually no discoverable local disorder whatever. Other young women are constantly coming to me from a distance with the statement that they have "ovarian disease" or "tubal disease" or "anteflexion of the womb," who are perfectly sound and who ought never to have been examined at all; and I have thus to record in my case book in numerous instances "no pelvic disease" or "metrophobia"—a word I have coined to designate those who are fully assured they have some grave "womb trouble" but are notwithstanding perfectly sound. Aside from all the hospital cases I have seen, I find in my private case book the records of 28 cases with no pelvic disease out of a total of 550 in all, about 5 per cent. While male physicians are great offenders in this respect, many of the women who practise medicine are far worse; in- deed, they often seem to possess no conscience whatever in dealing with these sacred interests of their own sex. A young woman with a natural sense of shame, but utterly guileless of any knowledge of anatomy, feels that it is easier for her to speak of her pelvic discomforts to one of her own sex, but the woman doctor (with many noble and conspicuous exceptions, I am happy to say) then feels, on her part, that it is necessary, in order to make a complete investigation of every case, to inspect the genitals and to insert her finger into the vagina; she generally ends by putting in a specu- lum, too, and tampons, and so begins a never-ending course of so-called "treatments," during which the natural ups and downs of health encourage the trusting victim to think at first that the "treatments" are benefiting her, and then, when the pains recur, that there surely is something serious at fault, and so it continues for years. Sooner or later, in many cases, an infection is introduced, and from having no disease at all she is inoculated with a salpingitis, and she is fortunate, finally, if she escapes a radical operation removing her uterine tubes and her ovaries. The records of this country within the past twenty years could show, I verily believe, thousands of such victims, at first unnecessarily insulted, and then robbed of their KELLY: THE PRESERVATION OF THE HYMEN. 3 distinctive organs of sex for imaginary ailments or diseases acquired. Such is the character of this evil; of its extent no one can do more than roughly estimate. My own experience leads me to conclude that these vicious practices are both general through- out our country, and that they affect our young-womanhood to the extent of inflicting an unnecessary injury upon many thou- sands yearly. What is the remedy ? First, there is no remedy where the man or the woman doctor does not possess a high moral sense of the obligation which rests upon him to respect the rights of every woman who comes to him as much as he would if she were his own daughter or his sister. This obligation is not lessened, nay, it is heightened, by the fact that the confiding patient makes no effort to defend her- self in her utter ignorance of the simplest anatomical facts; she, as a rule, has not the vague idea of the effects of a local examination. Second, the general practitioner who has not been specially trained in gynecological examinations should never undertake to make one in a young girl, except under the most stringent circumstances. If she has a large pelvic growth, that fact will be more evi- dent upon palpating and inspecting the lower abdomen. If she has some minor pelvic ailment he will not detect it, and in nineteen cases out of twenty he will mistake normal but sensi- tive organs for the various diseases he has been reading most about. Third, if the patient actually does have any form of pelvic disease and needs medical care, she can only be intelligently and properly treated locally by a specialist. Fourth, if the general practitioner is sometimes at fault, the sin far oftener lies at the door of the quasi-speciaMst who knows nothing of gynecology as a science and who examines and discovers an ailment in every inquiring female. Of these frauds, most of all, beware; they are the plague spots in the profession. Fifth, dysmenorrhea only calls for a local examination when it is aggravated and persistent and seriously interferes with the health, and the same may be said of excessive and pro- tracted menstruation. Sixth, I have to urge as a corollary to the foregoing that in 4 KELLY: THE PRESERVATION OF THE HYMEN. case an examination is actually necessary, it must be made by one who is thoroughly competent to decide at once whether or not there is any disease present, and who will be able to pro- ceed at once to do all that may be required to relieve it. By dilating a cervix, or rupturing a large Graafian-follicle cyst, or breaking up adhesions, oftentimes all can be done at once which it is possible to do at all, and the patient will be spared the distress of useless and endless so-called "treatments," which consist in the applications of drugs to the vaginal walls or to the cervix, anatomical structures distant from and quite distinct from the supposedly affected organs. The next capital point I would urge is that there are satisfac- tory methods of examining young women which need shock no sensibilities and which inflict no injury upon any organ. In the first place, if the patient has not been examined and treated before and an examination is necessary, it is my invari- able practice to propose to do this under complete anesthesia, in this way securing a perfect relaxation, with every facility for making the minutest investigation which it is possible to make, short of actual inspection through an abdominal incision. The anesthetic obviates the inevitable resistance of the abdom- inal walls, and the examination leaves behind it no disagree- able memories. In the second place, when the patient is anesthetized the examination must be conducted through the rectum. The cervix can be easily palpated through the recto-vaginal walls; and as for the body of the uterus, the ovaries, and the tubes, they cannot be clearly palpated in any other way. The rectal examination is therefore not only to be recommended because it spares the hymen, but because it is actually indispensable to a thorough investigation. I have shown on another occasion that the most minute ex- amination may be made by the rectum if the pelvic organs are first skeletonized by putting the patient in the knee-breast posi- tion to let in the air and so getting rid of the intestines. After doing this the examination is conducted in the dorsal position. If the finger is not more than 6.5 centimetres in circumference, it may often be inserted into the vagina, slowly and with ex- treme care, without rupturing the hymen; this is, however, not a good rule, for the tactile sense of many men seems to be so blunt that there is no appreciation of resistance when deli- cate structures are being investigated, and harm is done un- awares. KELLY: THE PRESERVATION OF THE HYMEN. 5 In the third place, if it is necessary to dilate and to curette the uterus, this may be done by introducing a finger into the rectum and locating the cervix, and then introducing a pair of tenaculum forceps into the vagina and carefully opening them, and catching the cervix and drawing it down to the outlet, where it may then be dilated and curetted, in many cases, with- out injuring the hymen. In the fourth place, the cervix and the vagina may be in- F.ARNOLD i SONS, BALTO. Fig. 1.—Speculum for use in vaginal examination of virgins. spected and treated through one of a series of specula which I have devised for this purpose, with the patient in the knee-chest posture and the vagina distended with air. These specula are cylindrical, like my vesical specula, but they have a shorter tube and are cut obliquely on the end, so as to do away with the necessity of using an obturator; the longest side, 6 centi- metres in length, is on the same side with the long handle ; the short side measures 5.6 millimetres in length. They vary in calibre from 8 to 18 mil- limetres. It is not infrequently necessary to examine little children, it may be not more than 2 or 3 years old, for leucorrhea or gonorrhea; I am not aware that this has ever been attempted, and yet it can be done perfectly with one of these small specula, through which I have been able to inspect the entire vagina and the diminutive cervix. If it is desirable to secure secretions from the upper vagina or from the cervix un contaminated by the secretions carried in from the exterior by an ordinary speculum, it may be done in 6 KELLY: THE PRESERVATION OF THE HYMEN. this way, for the instrument only enters the vaginal orifice and does not even touch the upper vagina. Fifthly, if treatments are necessary they may be readily and harmlessly carried out through a No. 10 or 12 or larger specu- lum. Solutions of nitrate of silver may be applied, as I have done, by means of an applicator to the vagina of a little child suf- Fig. 2.—Showing speculum in place and vagina distended by air. Patient in knee chest position. fering from gonorrhea, just as easily as in an adult woman through a Sims speculum. Sixthly, in an adult it may even be possible to remove a tumor, as I had occasion to do November 3, 1897. A young woman with an intact hymen had a mucous polyp, about 4 cen- timetres long and 12 millimetres in diameter, hanging out of the cervix, which I removed in the following manner without any injury to the hymen: KELLY: THE PRESERVATION OF THE HYMEN. 7 A cylindrical speculum 18 millimetres in diameter was in- serted, and the polyp, seen at the end of the speculum, was drawn into its lumen and held by a pair of rat-tooth forceps, while a catgut ligature was tied in a loop around the forceps and car- Fig. 3. Fig. 4. Figs. 3 and 4.—Removal of a mucous polyp in a virgin through a small cylindrical speculum. (Natural size.) ried down over the tumor and well up to the cervix, and tied around the pedicle of the tumor by means of a cotton and gauze packer which is pronged at the end and so affords a point of counter-resistance, pushing one end of the ligature up toward N KELLY: THE PRESERVATION OF THE HYMEN. the vaginal vault, while the other end was pulled down in the opposite direction, as shown in the figure. Another knot made this secure, and the tumor was then grasped just below the ligature to avoid cutting too close to it, and amputated with a delicate pair of scissors and removed. The patient, who had had constant hemorrhages, recovered promptly, has no consciousness of what has been done, and has no demonstrable physical sign that she has ever had a gynecological ailment or an examination. 1418 Eutaw place. MEDICAL JOURNALS PUBLISHED BY WILLIAM WOOD & COMPANY. MEDICAL RECORD. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. Price, $5.00 a Year. 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