GLUT^AL REGION 221 



from the inferior gluteal artery. The latter comes into view 

 medial to the ischial tuberosity, and is accompanied by small 

 branches of the inferior hsemorrhoidal artery. 



These nerves can most readily be found by everting the lower border of 

 the glutceus maximus ; but in doing this, care must be taken not to injure 

 the trunk of the posterior cutaneous nerve of the thigh, as it passes from 

 under cover of the glutceus maximus and runs vertically down the thigh. 



Deep Fascia. The deep fascia of the gluteal region is 

 brought into view by removing what remains of the super- 

 ficial fascia. The fatty tissue should be cleared away not 

 only from the deep fascia as it is spread over the glutaeus 

 maximus, but also from the more anteriorly situated area. 

 In the latter situation a dense, opaque, pearly white apo- 

 neurosis is by this means exposed. This covers the anterior 

 part of the glutaeus medius, and is firmly attached above 

 to the crest of the ilium. It stands in marked contrast 

 with the deep fascia over the glutaeus maximus, which is thin 

 and transparent. Subsequent dissection will show that the 

 dense fascia over the anterior part of the glutaeus medius, 

 when it reaches the anterior border of the glutaeus maximus, 

 splits into two lamellae which enclose the great glutaeus 

 between them. 



Dissection. Now proceed to clean the glutceus maximus muscle. If it 

 is the right limb, begin at the anterior or upper margin of the muscle ; but 

 if it is the left, commence the dissection at the posterior or distal border. 

 In undertaking this dissection, the dissector must keep clearly before him 

 the rules which have already been laid down regarding the cleaning of a 

 muscle: (i) render the fibres as tense as possible by rotating the limb 

 medially ; (2) remove the fascia in one continuous layer ; (3) always cut in 

 the direction of the muscular fibres ; (4) define very carefully the borders 

 of the muscle. 



The glutaeus maximus is a difficult muscle to clean, the fasciculi are so 

 exceedingly coarse. To do it well it is not sufficient to remove the fascia 

 which covers the muscle but it is necessary, at the same time, to follow, for 

 a short distance, the septa which penetrate between the fasciculi and to 

 remove them also. Do not remove the thick opaque fascia which covers 

 the insertion of the muscle. 



The dissector of the left limb, on reaching the anterior margin of the 

 muscle, will observe that the fascia which he holds in his hand is continuous 

 with the strong aponeurosis which covers the glutceus medius ; and further, 

 if he now frees the anterior border of the muscle from subjacent parts, he 

 will notice that the layer of fascia upon which the glutseus maximus rests is 

 also continuous with the same aponeurosis. In other words, he will, in this 

 manner, be able to satisfy himself that the strong fascia which covers the 

 anterior part of the glutceus medius splits into two layers to enclose the 

 glutceus maximus. The posterior cutaneous nerve of the thigh should 

 be secured at once by everting the distal border of the glutseus maximus. 

 Otherwise it is very liable to be injured in the subsequent stage of 



