The patient being laid on a suitable table, with the chest elevated, by placing a pillow or folds of cloth underneath. The head is next laid back neatly observing the direction of the mesial line strictly, and throughout the operation. The instruments previously got ready, and those which I prefer, are a scalpel with a sharp handle, a director and probe, two bistouries, one sharp and the other button pointed, a forceps, tenacula, sponge and ligatures. But so far I have never needed the ligatures. I have always stopped any little bleeding that occurred by applying a pencil of nitrate of silver. All these ready, also a basin of cold water, standing on the right of my patient, I place the finger and thumb of my left hand, one on each side of the thyroid cartilage, and commence my first incision from its lower third if a child, and from its lower edge if an adult, for obvious reasons, namely: In the child we want room, and if necessary can enlarge the incision in that direction, with but little difficulty, the cartilage affording no resistance. In the adult we have more room, and the cartilage is often found hard, and unyielding in persons of advanced life, and it is therefore necessary when enlargement is required in the adult, to cut an additional ring or more of the trachea. I continue my incision below the cricoid cartilage, so far as one or more of the rings of the trachea. The track of the operation being now laid off, I proceed cautiously, an assistant sponging, and applying caustic, as may be necessary to arrest any little bleeding that may ensue, whilst I, with the handle of my knife, push aside any vessel likely to bleed—cricoid artery or otherwise. I next lay hold on the cellular sheath of the trachea, at the lower edge of the track of my operation, and at this point I enter with a sharp pointed bistoury, holding it close to the point, and cutting upward not more than one-eighth of an inch and withdraw it in favor of the button pointed bistoury, with which I slit upward the windpipe, as far as the starting point of the first incision—not moving the instrument back and forth, but holding it perfectly steady, carrying it or rather pushing it, aided by the other hand from below upward, with the handle of the knife inclined downward. The operation now done, is made known by a whizzing which it is necessary to look after, and as all-important. I consider it the safety valve of the patient. This operation may also be performed from above, downwards, with a sharp pointed bistoury, holding it not far from the point; the forefinger on the back of the knife—taking care to help the cricoid artery out of the way, which I have always been able to control when cut, by the application of nitrate of silver. The patient may be, if necessary, turned on the side to prevent blood from passing into the windpipe.