502 



GLUTVEAL REGION. 



the posterior fibres of which are covered by the 

 glutaeus maximus. These anterior fibres have a 

 different action, varying in the different posi- 

 tions of the body in relation to the thigh, and, 

 according to this, consisting either in rotation 

 inwards, abduction, or flexion of the femur, or, 

 this bone being fixed, assisting in the various 

 anterior movements of the pelvis upon the thigh. 

 At the posterior edge of the middle glutaeus 

 is the pyriformis coming out of the upper open- 

 ing of the sciatic notch. Here, as we have 

 seen, the glutaeal artery is also emerging from 

 the pelvis and winding round the upper edge 

 of the notch. This, therefore, will be the situa- 

 tion of an aneurism of this artery, and a pul- 

 sating tumour being detected in the situation 

 just indicated by measure, as the seat of this 

 vessel, will be a very strong ground for deciding 

 both as to the disease and the vessel diseased. 

 A case lately came under our notice of a very 

 obscure character in which a swelling was 

 situated precisely in the position of the glutaeal 

 artery, but without pulsation or any other sym- 

 ptom of aneurism. The swelling was at first 

 indistinct, but as the surrounding parts wasted 

 under the effect of disease it became more pro- 

 minent. It was firm to the touch and rather 

 moveable, and about the size of a hen's egg. 

 But the principal part of the disease showed 

 itself within the pelvis in a tumour consisting 

 almost entirely of coagulum, as was proved by 

 puncture, situated behind the rectum, and 

 pressing it forward so as to occupy nearly the 

 whole pelvis, and obstructing the passage both 

 of fasces and urine. As there was no decided 

 symptom of aneurism no operation was at- 

 tempted for the relief of the case, and as the 

 girl, who is eighteen years of age, still lingers, 

 the nature of the disease is not yet cleared up. 

 But this part also occasionally gives exit to a 

 hernial tumour, part of the intestines or even 

 the bladder or ovary becoming thus displaced 

 and being lodged in the sac.* The superior 

 opening of the sciatic notch is bounded above 

 by the notch of the ilium, before by the de- 

 scending ramus of the ischium, and below and 

 behind by the superior sacro-sciatic ligament ; 

 and so large is the opening thus left that we 

 might expect to find the protrusion of some of 

 the viscera of the pelvis much more frequently 

 than we do. Yet so completely is this part 

 covered and defended by the pyriform muscle, 

 the plexus of nerves, the glutaei maximus and 

 medius, that this form of hernia is an extremely 

 rare occurrence. When it does occur in the adult, 

 the diagnosis is very difficult while the hernia is 

 small, owing to the great depth at which it is 

 situated. When, however, it is congenital, the 

 nature of the swelling is larger in proportion to 

 the size of the surrounding parts, and the depth 

 of the superjacent parts less ; yet even here 

 Professor Schreger did not at first detect the 

 nature of the swelling. In fact nothing but 

 the actual feeling of the guggling of the gas of 

 the intestines under the finger seems sufficient 



* See a summary of cases of ischiatic hernia in 

 Cooper's First Lines of Surgery. 



to discriminate the case, and this is of course 

 not to be expected when the gut is strangulated . 

 Indeed, in Dr. Jones's case* the symptoms 

 were not at all referred by the patient to the 

 true seat of the disease, and the surgeon was 

 in consequence never led to make any external 

 examination of this part. It may be well to 

 state here the anatomical relations of the hernial 

 sac in this case, which was carefully dissected. 

 " A small orifice in the side of the pelvis, 

 anterior to but a little above the sciatic nerve 

 and on the fore part of the pyriformis muscle, 

 led into a bag situated under the glutaeus maxi- 

 mus muscle, and this was the hernial sac, in 

 which the portion of intestine had been stran- 

 gulated. The cellular membrane which con- 

 nects the sciatic nerve to the surrounding parts 

 of the ischiatic notch had yielded to the pres- 

 sure of the peritoneum and viscera. The orifice 

 of the hernial sac was placed anterior to the 

 internal iliac artery and vein, below the obtura- 

 tor artery and above the obturator vein. Its 

 neck was situated anterior to the sciatic nerve, 

 and its fundus, which was on the outer part of 

 the pelvis, was covered by the glutaeus maxi- 

 mus. Anterior to but a little below the fundus 

 of the sac, was situated the sciatic nerve, 

 behind it the glutaeal artery. Above, it was 

 placed near the bone, and below appeared the 

 muscles and ligaments of the pelvis." 



We must not conclude this article without 

 a few words on the general form of the glutaeal 

 region as affording an important means of 

 diagnosis in disease. In examining this re- 

 gion in a healthy person we observe, 1st, the 

 thick rounded prominence of the nates, formed 

 by the posterior and inferior margin of the 

 glutaeus maximus ; 2d, the projection of the 

 trochanter major, only covered by the integu- 

 ments and the thin tendon of the last-named 

 muscle; 3d, the projection of the crista ilii, 

 forming the upper boundary of the region ; 

 4th, a depression, perpendicular in direction, 

 between the nates and the trochanter major ; 

 5th, another depression, slighter than the last 

 and transverse in direction, between the tro- 

 chanter and crista ilii. 



Now almost all these points become altered 

 in character and relation in disease. In dislo- 

 cation of the femur they of course are changed 

 by the difference in position which the trochan- 

 ter assumes in common with the head of the 

 bone ; and according to the unnatural situation 

 which this occupies, so will the alteration in 

 the general form of the parts be modified. But 

 we now speak particularly of the changes of 

 disease. Even in the inflammatory stage of 

 disease of the hip-joint, it is surprising how 

 great is the effect produced upon the nates. 

 The roundness and fulness gradually go, the 

 nates looks wasted, and the depression between 

 this and the trochanter disappears. This wast- 

 ing, arising from interstitial absorption of the 

 glutaeus and parts adjacent, is the more striking 

 as it occurs too rapidly upon the affection of 

 the joint to be the effect of inaction of the 



* See Sir A. Cooper on Hernia, part ii. p. 67. 



