A Woefully Incomplete History of the Treatment of Imperforate Hymen

Here's something that definitely makes my head go phoom. My friend Kalen Hughes at History Hoydens, a blog by historical romance writers, wrote me asking if I knew how an imperforate hymen might have been treated within the last, oh, 500 years. It seems this came up in the comment on her post about how "first time" sex scenes in romance novels often have the guy well past where the hymen actually is before ramming into it like a runaway train.

So here comes the first bit of explanation. I haven't blogged about this, but my hobby is reading up on the history of medicine, specifically, the history of surgery. Even more specifically, the history of surgery, the techniques and social status of surgeons, in 16thC Germany. Someday, I will blog about how I got into this and why I find it interesting. When there is some weird question about how the body and it's various bits were viewed in the past, friends quiz me.

And as they have already learned and you will soon learn, I am not freaked out by any subject. I'll get my warning out of the way now. I will be linking to sites and photographs that feature vaginas because I honestly hate typing and if I can show you a picture of an imperforate hymen, then I will (and I will).

Before we delve into how past surgeons or doctors might have viewed or dealt with imperforate hymens, it's important to demystify the hymen and then clarify what we know now about imperforate hymens.

If you really don't know what a hymen is, just start at the wikipedia entry on hymen. If you think, "I don't need no stinkin' wikipedia", that's fine. The important points here are:

• The hymen is *outside* the vagina. (And if that's news, they you *do* need the stinkin' wikipedia article.)
• There is a wide range of configurations (see Illustrations of the hymen in various states), thickness and elasticity. Generally, the hymen becomes thin and elastic with the onset of puberty so there's no tearing or blood during sex, but that's not always so.
• Because the hymen varies in how much of the vaginal opening it covers and because it is elastic, it's impossible to define what an intact hymen is and so the condition of a hymen is *not* a good indicator of virginity. (Further down, I'll point out some historical cases of women becoming pregnant despite their hymens being "unruptured".)
• In some women, the hymen does completely cover the vaginal opening. This is known as "imperforate hymen". And contrary to wikipedia's authoritative "1 in 2000" occurrence, according to the emedicine.com article on the "imperforate hymen", the occurrence has been reported from 1 in 1000 to 1 in 10000.

Focusing on the imperforate hymen. Here are some quick notes from that emedicine.com article:

• "Variations in hymenal anatomy commonly escape diagnosis until the time of menarche". So, even our modern medicos have trouble diagnosing this until a girl has her first period. (In some cases, mucous secretions will collect at birth and cause the imperforate hymen to bulge aiding in identification.
• Even if an imperforate hymen is detected at birth and unless there is an immediate problem, it's recommended to wait until puberty when the onset of estrogen will help prevent scaring of the tissue when it is surgically cut.
• When a girl with an imperforate hymen reaches menarche, the menstrual flow will have no where to go. This will cause the hymen to bulge and look bluish. If it goes untreated (it's not an emergency situation), her symptoms will include cyclic lower abdominal pain, menstrual like cramps, pressure on the bladder and rectum. If it remains untreated, her abdomen might also bulge. (See also the emedicine article on Outflow Obstructions and, as promised, pictures). This can go so far as to block the urinary tract and overflow the bladder (which will cause more abdominal pain, pressure on the rectum and vomiting). In the worst cases, fluids can build up and organs can rupture. (See Imperforate hymen as a cause of bladder perforation and intestinal obstruction.)

So now we know *way* more about imperforate hymens than we wanted to know. Let's see what we can find historically. Not as much as I might have hoped.

The 1901 edition of Anomalies and Curiosities of Medicine by George M. Gould and Walter L. Pyle there is a fair amount of discussion of cases where pregnancy occurred despite the fact that the hymen was not ruptured. Additionally, there are examples of women who gave birth without rupturing the hymen. There are also examples of hymen so ridged they do not allow penetration, and needed to be removed during labor in order to prevent it from obstructing the birth. Imperforate hymen is mentioned twice:

H. Grey Edwards has seen a case of imperforate hymen which had to be torn through in labor; yet one single act of copulation, even with this obstacle to entrance, sufficed to impregnate.( CHAPTER 1. GENETIC ANOMALIES.

Foucard 15.111 reports a case of retention of urine in a young girl of nineteen, due to accumulation of the menstrual fluid behind an imperforate hymen. (CHAPTER 15. ANOMALOUS TYPES AND INSTANCES OF DISEASE.

The second case fits the cases of outflow obstructions, but the first case where she became pregnant is pretty wild. Something I did not find in the modern medical literature I read so far is if the hymen membrane is porous to sperm. If anyone finds something relating to this, I'd like to know. It's not enough to assume that just because an imperforate hymen can block mucous and menstrual blood that it can block semen.

Hitting up PubMed, I came across an survey of 19thC adolescent gynecology that lists in it's abstract: "A review article in 1891 reported a 10% mortality rate associated with treatment of the imperforate hymen." (The early historical roots of pediatric and adolescent gynecology. Yordan EE, Yordan RA. Journal of pediatric and adolescent gynecology. 1997 Nov;10(4):183-91.)

Hang on a sec. There were enough instances of imperforate hymen prior to 1891 that someone could estimate a mortality rate? I will want a copy of this full article so I can read that 1891 report to see under what circumstances the surgery on the imperforate hymen was performed. (Ignore the fact that I am more curious about the possible rate of incidence than I am about mortality -- I'm used to reading about the 16thC when you were lucky if a procedure had a 50% mortality rate). I'm curious to know how many cases, what age the girls were when treated and if there are any hints about the complications that might have caused death.

Unfortunately, after this, the trail grows cold for me. Obstetrics and gynecology are not areas where I have chosen to buy books so I need some encouragement to keep researching this.

Thinking it through (often unwise without actual documentation)....

Gould and Pyle make references to stories of hymens that prevented actual coital penetration (and yet pregnancy occurred) back to the 16th and early 17thC (citing Fabricius Hildanus and William Harvey among many others). Also, it seems that depending on the nature of the hymen at the time of labor, it would either rupture during labor or it would need to be cut if it was too "fibrous" (thick and inelastic).

Knowing that surgeons of the early modern period did not hesitate to apply the knife, especially if what they were facing was not typical or ideal, I'll hypothesize that faced with an imperforate hymen, especially when it is blocking menstrual flow or obstructing a normal birth the surgeon or midwife would have simply cut it with a knife. What I cannot guess at is how much they would have cut (a single slit or circumscribe the opening) or what, if any, after care would have followed and how that might have changed with the increased understanding of circulation (William Harvey, 1628) and staunching post-partum hemmoraging.

If anyone has resources or is willing to add to the research on this topic, please add a comment. I find these specific questions interesting because they require taking into consideration societies view of the body, common medical knowledge at the moment and learning what we really know about the condition.

SecondLife for Nonprofits - Two Mixed Reality Events

Two seperate groups inspired by the Net Squared gathering of web innovators who promote social change are holding back-to-back events to discuss the potential of nonprofits making effective use of the virtual world platform, SecondLife.

Both are on July 18, 2006. Both take place partially inside SecondLife at the TechSoup online meeting space. BUT they each will be holding a simultaneous meeting in the physical world with video and audio being passed between the online and phsycial meeting spaces so both sets of participants can see and hear each other.

First up on July 18 at 3:30pm Pacific/6:30pm Eastern, the Ethos Roundtable will feature an introduction to Second Life. John Lester, Community Manager at Linden Lab, (the company that created and runs Second Life), will present a tour of this online community including how Second Life can be used for educational and non-profit work. John will have slides and also give an in-world demo to show you how Second Life works.

Ethos Roundtable event physical location:
77 Huron Avenue (Yahoo!Maps)
Cambridge, MA

Soon after that at 6:30pm Pacific/9:30pm Eastern, TechSoup will present on how nonprofits can effectively use SecondLife. Susan Tenby, Online Community Manager of TechSoup.org, and Jeska Dzwigalski, Community Manager at Linden Lab will also present a tour of this online community, including TechSoup's satellite office and demo a directory of nonprofit organizations in the Second Life world. The event will feature a number of guest speakers from organizations who are actively working in the Second Life community to better achieve their organization's missions.

I'll be attending the TechSoup event in both the physical and online sense. I'm easy to spot in SecondLife as I made my avatar look like me (though avatar customization hasn't quite caught up with my actual beard growth).

TechSoup event physical location:
Net^2 HQ
322 Ritch St. 2nd Floor (Yahoo!Maps)
San Francisco, CA
415-633-9446

BOTH events take place online in the same online location. Go directly to the TechSoup area in SecondLife by following this SLurl:
http://slurl.com/secondlife/InfoIsland/52/171/33/

To ensure smooth operation of the online event, the organizers will restrict the TechSoup space to 50 members, and they will allow those in on a first-come-first-serve basis. Arrive early to secure your spot.

You will need to download (25-50MB) and register (free) for SecondLife to visit the online location. I strongly recommend you make sure you can run SecondLife early as it has some fairly strict system requirements.

Once you get started, take a look at the SecondLife Wiki for some more info on how to operate SecondLife. (Or just hit o get the chat input and start asking people for help.)

Also read what some nonprofits, innovators and activists are doing in SecondLife.

Other folks who blogged recently about nonprofits in SecondLife:

Non-profits in Second Life at Omidyar Network

Nonprofit Life in Second Life at Spare Change

Announcing the TechSoup Second Life Event: July 18th at 6:00 PM PST at Beth's Blog

Second Life for Nonprofits at sufolla - community weavers

Tech Soup to offer mixed reality event in person and in second life at Second Life Library 2.0

Are you drinking the Metaverse Kool-Aid?

Over the past year, I've been encountering more and more people enthusiastic about the potential of a Metaverse in the vein of Neal Stephenson's Snow Crash. Today, we have the Metaverse Roadmap project and an Open Source Metaverse Project. Break out the Kool-Aid because it's deja-vu all over again.

I first read Snow Crash 10 years ago as required reading for working on VZones (nee WorldsAway) and, at the time, I was struck by the dystopia that Stephenson develops in contrast to his Mardi Gras vision of the Metaverse. I was particularly mindful that what made the virtual world so alluring was that the physical world was such a economic, political and social mess. It seemed to me that people in the novel entering the Metaverse were seeking something the bleak logo-festooned burbclave reality could not offer, whether it was entertainment/distraction or connection/contacts. It was in a very palpable way a Hyperreality - an idealized imitation or simulation of reality that, through it's simulation, is better than the real thing. Disney's Main Street USA is a hyperreal vision of America. Historical reenactment is a hyperreal vision of history.

After the most recent Game Developers Conference, I felt the urge to pick up Snow Crash once again, just to see if perhaps the years had added additional layers to my view that the Metaverse was not a practical vision for wide-reaching socialization technology. I can say that the years did little to change my view. If anything, the intervening years of text messaging, blackberries, and other mobile connectivity devices that are incapable of rendering 3d polygons, but are great at simply and quickly connecting people reinforce my opinion that modeling after the Metaverse as technology, tends to blind folks to the social implications.

In other words, regardless if you want to bring people together online for economic reasons, political reasons, cultural reasons or social reasons, don't be distracted by blue technology such that you forget why you are doing it in the first place.

I could use your help with a design

So I actually convinced my foundation that getting public feedback on designs is a good idea.

It's not an earth-shattering feature. It's just some functionality to help one registered member of a site send their email address to another registered member.

See, families of kids with learning and attention problems face more than just educational and emotional or social challenges. They are often in conflict with schools, sometimes with spouses and sometimes defending their children from law enforcement or child protective services. Any of these can lead to court, but even before then, parents are very very concerned that their lives will be *too* exposed. Over 2/3rds of our registered members have chosen to *not* display their email on their public profile. 'Nuff said.

So given that parents generally know each other only by their screen names, how can I help them make a better contact so they can have private conversations with other parents?

Before you even ask, private messaging is not one of our options.

The main reason we aren't opening up PM is that we don't want to host all those messages. Harassment, illegal behavior and all sorts of problems can occur via PM and to avoid having our time sucked up by hearsay arguments, we should keep a record of every PM and *that* opens us up to a lot of responsibility that our small shop just can't handle.

Another reason is that I am blissfully free trying to pump up our site traffic. My goals are measured in lives affected so I don't have to inflate traffic. If two people meet and go off into email to work out problems, great stuff.

So the challenge is to limit the interaction, give control over the personal information and the interactions to the members and minimize the ability to break it for nefarious purposes. Here's where my community minded friends come in.

I would really appreciate it if you could take some time to look at the design I am working on and offer your insight and feedback. Have I plugged the holes? Are there more elegant ways of handling this? Take a look at my Parent to Parent Email Exchange Design.

You can comment here, email me or join our parents in the discussion where they are offering their views something to be built for their needs.

Fight Machine!

Just for fun: Fight Machine!

As you can see, the first opponents I entered have been influenced by my past three months of reading a heavy dose of skeptic blogs such as Respectful Insolence (a.k.a. "Orac Knows"), The Millenium Project, Skeptico, Bad Astronomy Blog and A Photon in the Darkness.

And what's funny about being so deep into reading skeptical writers is that I spend much of my time reading about 16th Century medical beliefs and surgical practices such as bloodletting and the four humors, cupping, herbal remedies, astrology and, hey let's not forget, uroscopy. (Sorry no link for astrology, I was trying to find a 16thC image of a bloodletting chart.) All of these survive today in some form or another as alternative therapies or as we now know to call them, quack medicines.

So I enjoy delving into the 16thC mind and have mixed up a few herbal wound salves to make 7th graders wrinkle their noses (egg yolks, rose oil, turpintine - which of course comes from a gum resin disolved in brandy) and even learned to use glass cups. And while I have learned how some of these practices had some beneficial (if slight and then misunderstood) effect which might prove interesting today such as using leeches for modern microsurgery, I'm not in the least fooled into thinking that understanding of the world 500 years ago was some how more reliable than what we are capable of knowing today.

So back to the fight.... the Quacks lose.

Virtual World Celebrates 10 Year Anniversary

Today at 5PM Pacific Standard Time, the virtual world Dreamscape running on the VZones platform will be officially 10 years old.

Dreamscape circa 1995

From 1995 to 1998, I was one of the community managers and honestly, I didn't expect the place to still be around. Fujitsu had sunk several million dollars into a new version of the Habitat world. The idea was that it could be a platform which could be licensed to others who would build and maintain their own worlds. In order to convince the world that the platform was a place for viable online communities within a virtual environment, a flag-ship product was planned. The profitability of this flag-ship community was always on the mind of Fujitsu and there were times the whole project was almost scuttled before it launched.

Oracle Uni, Oracle Teresias (Me) and Oracle Vaserius welcome Brother Echo (bald man in the back) to being a World Manager (1998)

So, it's really wonderful to see that, 10 years later, much of the central planning over user created content has been decentralized. When we started, there were few objects that did things and little artwork to keep the illusion of variety fresh. 10 years ago, there were 3 Oracles inside the world "managing" the social and physical layout of the world who oversaw about 20 volunteer Acolytes helping settle dispute and handle serious troublemakers. Today, the official staff roster includes Director, World Managers, Senior Oracles, Oracles, Acolytes and Acolyte Painters, or roughly 60 people.

But that's not all, some of these staff are responsible for helping guide Pans, Proprietors, Mages, Muses, Creators, Natives, Welcomers, Security Bears, Jesters, Thespians, Sprites. I don't know how many people are on the rosters of each of these. But that's not the important bit part. These volunteer subgroups fall into two basic categories: content creators and support. Mages, Muses and Natives and the other fantasy named groups create stories of the world, often retelling events that actually happened. The Proprietors, the Welcomers and the Security Bears support the trade of objects, the integration of newcomers and crime prevention education.

While it's not fully decentralized, the inverse pyramid of support where the world director supports, the world managers who support the volunteer groups who support everyone else is much, much bigger and more capable that what we were doing 10 years ago. The key to this little virtual world hanging in there for 10 years is that the people inhabiting the world have many more opportunities to have a lasting effect on the world and others who come after them. The world is much more vibrant than when I was there 7 years ago and it shows.

Dreamscape in 2005

You've come a long way baby. Here's to you!

It is my sad duty to inform you...

That I am home. Yeah, it took a week for me to post. I survived the Prepetually Screaming Child (three cheers to my mp3 CD player and rechargable batteries), jet lag and even my first week at work. For those keeping score:

- I did not check my bag once during my entire trip. It was worth all the fussing over what to pack and handwashing every night just to breeze through the "nothing to declare" gates at every airport.

- My most worrisome moment was not Berlin con-men, but having the German passport control wonder why I didn't have an entry stamp for Germany. Luckily, they make a joke about Italian passport control and let me go.

- According to my passport, I have entered the UK twice, but I have never left. I haven't left Italy, but I definitely left Germany without ever having been there. Way to go security forces of the EU!

- After three weeks of driving in Germany, I am still driving at 130km/h and highly annoyed at people who are simply cruising in the far left lane.

- My cell phone is still dead. I'm trying to swap out the battery. Grrr.