THE VAGINAL EXAMINATION.
a. The simple Vaginal Examination.—The vaginal examination neces. skates patulousness of the canal, or at least of the ostium. Generally the patency will be interfered with by the presence of the hymen. An imperforate hymen, like any other closure of the ostium vaginae or of the canal itself, constitutes an absolute obstacle which must be overcome by surgical means. The same holds true of abnormalities of the hymen, as, for instance, the cribriform hymen, and of congenital or acquired uar rowings of the vagina or of its introitus, which do not allow of the inser tion of the finger into the lumen of the genital eanal. Here a nutting or forcible dilatation must precede the vaginal touch. The normal hymen rarely constitutes much of an obstacle to the touch. Naturally, examina tion of young girls must be limited strictly to exceptional cases, but it must not be neglected in cases of necessity, on the ground that it is diffi cult. Ordinarily the hymeneal opening may be distended sufficiently by the well-anointed and carefully inserted finger, without inflicting great pain, especially if we follow Elischer's advice, and tell the patient to bear down strongly during the examination. The recommendation of certain gynecologists to examine with the little finger, is of no utility and pro ductive of insufficient results. Besides, chloroform is useful, and it should be administered in face of the psychical and physical results of the examination. In case the hymen is crescentic and open above, by press ing up the bulb of the urethra sufficient space is readily obtained without pressure on the sensitive hymeneal border. In case it is impossible to insert the finger, as often happens in more mature girls, then it is better to knick the hymen in a number of places than to tear it violently.
The examination of the hymen is important from a medico-legal standpoint. It is, as is readily understood, a very difficult matter in the majority of cases, or rather impossible, to deduce a conclusion in regard to virginity from the appearance of the genital organs, and the law is satisfied with data in regard to penetration, and on this point the hy meneal edges give the most important evidence, although not sufficient for all cases. Since, in order to answer this question, it is especially im
portant to examine the free border of the hymen for the absence or the presence of tears or cicatrices, it is necessary to stretch the hymen equally as much as possible. The patient should be placed in the dorsal position, with the buttocks elevated, the thighs abducted and flexed, the labia majora and minora palled apart; and we endeavor by equable traction, or by pressing out the hymen by a sound inserted in its orifice, or by a catheter in the bladder to obtain a good view. Often this procedure is difficult, not only from the resistance of the patient, but because of the deep site of the hymen, which is often the case in women who are ex amined from a medico-legal point of view, since repeated attempts at intromission may in case of resistant hymen push it in a considerable distance from its normal site. In case the hymeneal edges are fimbriated, etc., it is obvious what a difficult matter it is to reach an opinion, the more so from the fact that the physician must be careful not to cause a rupture himself which, as has happened, would lead to an erroneous opinion. In these instances, a rubber bag is very useful, for it may be inserted collapsed, and in distension the hymen lies against it, and we may examine its edges without fear of rupture.
Similar obstacles are offered by narrowness of the introitus vaginae, by recent marriage, and the presence of the inflammatory and nervous forms of vaginismus. In these instances resort to chloroform is useful, although much may be accomplished by the use of baths, the local appli cation of narcotics, etc.
Tumors of the external genitals and of the vagina, such as cysts and fibromata, further, large tumors of the uterus and its annexes, or of the bony pelvis, where they involve the lumen of the vagina, may interfere with examination. As further obstacles may be enumerated, acquired atresia of the vagina, congenital or acquired narrowness, exudations in the neighborhood. Acute inflammatory processes hinder the vaginal touch, on account of the pain involved.