5°2 GLUTÆAL 
the posterior fibres of which are covered by the 
glutæus 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 glutæus 
is the pyriformis coming out of the upper open¬ 
ing of the sciatic notch. Here, as we have 
seen, the glutæal 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 glutæal 
arteiy, 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 faeces 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 wre do. Yet so completely is this part 
covered and defended by the pyriform muscle, 
the plexus of nerves, the glutæi maximus and 
médius, 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. 
REGION. 
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 glutæus 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 glutæus maxi¬ 
mus. Anterior to but a little below the fundus 
of the sac, was situated the sciatic nerve, 
behind it the glutæal 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 glutæal 
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 i 
glutæus 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 
w’hich 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 
glutæus 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.