224 INFERIOR EXTREMITY 



(2) branches of the inferior glutteal artery and the inferior glutical nerve 

 below the level of the piriformis. The veins may at once be removed, 

 but the arteries and nerves must be systematically cleaned as they come 

 into view, and traced into the substance of the glutceus maximus. Penally, 

 to allow of the complete reflection of the glutaeus maximus, these vessels 

 and nerves must be cut, and it is advisable to leave in connection with 

 the cut end of each a small portion of muscle-substance, in order that 

 they may be readily recognised in the further steps of the dissection. The 

 whole muscle may now be thrown distally and laterally, and after a little 

 dissection an admirable view is obtained of its insertion. Piercing the 

 distal part of this there will be seen a few small twigs of the first perforat- 

 ing artery a branch of the profunda femoris. 



In the case of the right limb the procedure adopted in reflecting the 

 gluteus maximus is the same as detailed above, with this exception, that 

 the dissector should begin by detaching it from the coccyx and ligamentum 

 sacro-tuberosum and work upwards towards the ilium. 



Although it is recommended that the glutseus maximus should be 

 reflected proximo -distally, it is right to mention that an equally- 

 instructive view of the subjacent parts may be obtained by detaching it 

 from its insertion and throwing it upwards towards its origin. The senior 

 student would do well to adopt this method. 



Bursae Mucosse under cover of the Glutseus Maximus. Two 

 bursa are found in relation to the insertion of the glutaeus 

 maximus. The one a large loose sac is interposed between 

 the aponeurosis, into which the proximal part of the muscle is 

 inserted, and the great trochanter of the femur. It allows the 

 aponeurosis to play freely on the bone. The second bursa lies 

 immediately distal and anterior to the part of the muscle 

 which is inserted into the glutaeal tuberosity of the femur. 

 A slight touch of the knife is sufficient to open it, and 

 then the glistening tendon of the vastus lateralis comes into 

 view. The bursal sac intervenes between this tendon and 

 the aponeurotic insertion of the glutseus maximus. 



A third bursa is situated between the glutaeus maximus and 

 the tuber ischiadicum. In all probability this has already been 

 explored by the dissector of the perineum. It lies over the 

 lower aspect of the bony prominence, and is interposed 

 more between the tough superficial fascia and the bone, than 

 between the muscle and the bone. 



Dissection. On the second day the dissector undertakes the dissection 

 of the remaining structures which are displayed by the reflection of the 

 glutceus maximus. The vessels and nerves which have been partially 

 exposed in the previous day's dissection must now be followed towards 

 the pelvis, and the remaining vessels and nerves, together with the muscles, 

 must be defined and cleaned by removing the loose areolar tissue which 

 covers and passes between them. 



Parts under cover of the Glutseus Maximus. Pro- 

 ceeding, from the dorsum ilii distally, towards the tuber 



