The trigonum is brought into view by withdrawing the speculum until the internal urethral orifice just begins to close over it, and then pushing it in a little and dropping the handle slightly. This por tion of the bladder is as a rule a little more injected and rosy than the rest of the mucosa. The inter-ureteric ligament is sometimes marked as a distinct rounded transverse fold. By turning the specu lum to the right or left about thirty degrees, with its end projecting 1 cm. into the bladder, the right and left ureteral orifices can be brought successively into view. The ureteral orifice usually appears as a little slit, about 3 mm. long, placed transversely with a slight horseshoe-shaped elevation around it, open on the inner side.
Usually, with the woman in the knee-breast position, the ureteral orifice is found on the inner side of a decided eminence, having the form of a truncated cone (mous ureteris). The ureteral orifice may at times appear as a little pit or hole in the mucosa, at other times as a rosette with the opening in the centre. If the observation is continued for a minute a little jet of urine will be seen to spurt out of the ureter for two or three seconds. The ureter then closes to be opened by another jet within the following minute. I have repeat edly seen pus or blood escaping from one ureter, while clear urine escaped from its fellow.
The ability to find the ureter readily is developed by practice. An experienced observer will introduce the speculum and turn it to ward the side in question, and with one or two slight movements of adjustment, pushing it, withdrawing it, or turning it a little, will have the ureteral orifice within the field of vision within two or three seconds.
Occasionally the bladder presents some little depression which the examiner cannot be sure is not the ureteral orifice. The doubt may be readily settled by taking up the searcher, which has a strongly curved handle, keeping it out of the field of vision, and introducing its point into the opening. If it is the ureter, the searcher will pass readily 3, 4, or even 6 or 8 cm. (1, 11-, 2, or 3 in.). I have not noticed any special sensitiveness about the ureteral orifice.
In the virgin, it may be difficult to find the ureteral orifices, owing to the fact that the bladder balloons out too much, carrying the base high up toward the sacrum. To gain even an unsatisfactory view under these circumstances, the observer has to get his head almost under the patient's body. This difficulty will be overcome by taking the precaution beforehand to introduce a speculum into the vagina, in order to distend it with air. This prevents the excessive disten tion of the bladder in this direction.
That portion of the bladder which lies behind the symphysis may be inspected by elevating the handle of the speculum very decidedly and looking down toward the anterior part of the vault.