I begin close by the lower edge of the thyroid cartilage, and carry it so far as the second ring of the trachea; but in either case, whether I open upward or downward, the tenaculum can materially assist in the operation, by drawing down the tube when cutting upward, or by drawing upward when cutting downward—the hook to enter behind the knife in either case. The use of the hook is most necessary when operating on young children. The object in pushing the knife, holding it steadily, is from knowing that it long since has been found, that an artery will give way before a knife when carried in this way that might otherwise have been cut immediately by a “see-saw” motion. After the operation is performed, I direct the attendants to keep the opening clear of obstruction—bloody froth, &c., or anything that may make its appearance in the wound. Artificial respiration must be kept up until the foreign substance is expelled or removed. A probe or knitting needle will suffice for that purpose, one or the other must be used several times a day and night, in fact as often as needed; I use no gauze, it might get sucked to, or drawn into the opening, and thereby defeat the intent of the operation. In cases needing the use of the canula I make no reference. I prefer laryngo-tracheotomy, sometimes denominated circo-tracheotomy, which I have been endeavoring to describe, to any other, for all ordinary purposes. We have less risk, and more room, and it is more adapted to the relief of children and might with propriety be called the higher operation to distinguish it from tracheotomy, which rightly speaking is the lower operation. This would draw a distinction between the two, and it is necessary that line should be observed, and that when these operations are spoken of, we should know what importance to attach in either case, and give to either operation the degree of approbation it may deserve.