pushed out of the way, or if necessary cut and tied, and all parts held aside by removing and replacing freshly the retractors from time to time as the dissection proceeds, until the ring of the cricoid and the upper rings of the trachea come plainly into view; that is, are seen, not alone felt. During this dissection, especially if the handle of the scalpel be used, too much pressure must not be made upon the trachea. More than once I have known it to cause sudden suspension of the respiration, probably by exciting reflex spasm of the larynx. If the isthmus of the thyroid gland extend far upward, it must be pressed downward, its facial attachments to the cricoid and trachea cut or torn through, and may require to be held downward in the lower angle of the wound by an additional retractor. The upper rings of the trachea having been thus well cleared of their overlying parts, the next step of the operation follows. I am in the habit of now removing the retractors and allowing the trachea, which may have become displaced by them, to resume its normal position, the head of the patient being meanwhile readjusted. All this takes but a few seconds. A tenaculum is then implanted in the median line, either just below the edge of the thyroid or the cricoid cartilage, if the latter is not to be severed, and held firmly by the assistant at the head of the table, thus steadying and elevating slightly the trachea and rendering the incision into it certain. The retractors are now reintroduced at the sides of the wound, and the operative field is clear and steady. A glance having shown that all bleeding has ceased, another that the tracheal dilator and tracheotomy-tube lie ready at hand, the operator plunges a straight-pointed bistoury through the tracheal wall at the level of the third or fourth ring in the median line, and cuts quickly upward until the cricoid cartilage is reached, if he proposes, as in the adult can usually be done, to limit his operation to a superior tracheotomy. If not, as in the child, and the cricoid cartilage must be cut through to gain sufficient space for the introduction of the tube, it also is severed by prolonging the incision upward to the thyro-cricoid membrane. A hissing of escaping air, with the bubbling of a little blood and paroxysms of cough, follows the incision and shows that the trachea has been fairly opened. The tracheal dilator is now introduced, the lips of the tracheal wound separated, and the canula slipped neatly into the windpipe (unless in the case of a foreign body), and secured a moment or two later, when respiration is fairly established, by tapes passing around the neck. The tenaculum and retractors are removed at the same moment that the tube is slipped into place.