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The Pocket Guide to
Critical Appraisal
The Pocket
Guide to Critical
Appraisal
SECOND EDITION
Iain K. Crombie
University of Dundee
Dundee, UK
This second edition first published 2022
© 2022 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording
or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material
from this title is available at http://www.wiley.com/go/permissions.
The right of Iain K. Crombie to be identified as the author of this work has been asserted in
accordance with law.
Registered Offices
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office
9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, customer services, and more information about Wiley
products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some
content that appears in standard print versions of this book may not be available in other
formats.
Acknowledgements ix
Preface to the First Edition xi
Preface to the Second Edition xiii
v
vi Contents
ix
Preface to the First
Edition
xi
Preface to the Second
Edition
xiii
xiv Preface to the Second Edition
1
2 Chapter 1 Introduction to critical appraisal
presents appraisal tools for the six most common research designs in
medical research (Chapters 6–11).
A key feature of the questions on bias is that they distinguish
between critical and important sources of bias. For each research
design there are a few crucial steps which, if conducted poorly, are
very likely to lead to misleading findings. Flaws in the other steps
are less likely to cause serious bias. Only when several of these flaws
occur are serious concerns raised.
Value, the usefulness or worth of a finding to individuals and to
society, is more difficult to assess. Assessing the potential for improv-
ing health is usually straightforward, but often some pieces of infor-
mation, such as the importance of the findings to patients, are not
available. Decisions about value can use information from several
sources and require judgement to balance many complex issues.
Apply the tool to assess the bias and the value of the
research
The critical appraisal questions can only be answered by identifying
key pieces of information from relevant sections of a paper. Chapter 2
provides a simple method for extracting the key pieces of information
from a research paper. Careful reflection on what the questions reveal
enables an assessment of the quality of the research study.
The appraisal questions presented in this book are structured
to lead to one of three answers: yes, no, or not enough information
to decide. Selecting the appropriate option is not a simple tick
box process. Critical appraisal involves pausing to think about the
implications of each limitation, and whether it could seriously affect
the interpretation of the study’s findings. Sometimes there will
be insufficient information to answer a question. As decisions in
medicine affect patients, it is usually better to be cautious in drawing
conclusions.
In summary, critical appraisal assesses the bias and the value of
research studies. By identifying the research design, the appropriate
appraisal tool is selected. It asks probing questions about the design
of the study and the way it was conducted, analysed, and interpreted.
Chapter 2 describes a simple method for extracting the information
from published papers to facilitate critical appraisal.
CHAPTER 2
Do Not Read the Paper
4
The initial interrogation 5
flaws that reading may miss. It provides all the information needed
to evaluate the risk of bias and value of the results.
Surveys
7
8 Chapter 3 Identifying the research design
Essential features
Surveys take samples from a target group or population. The idea
behind this is that a well-taken sample contains almost as much
information as would come from studying the whole population.
In principle, surveys obtain a complete list of the group or population
of interest from which a sample of individuals is selected for further
study. The selection is carried out randomly (not haphazardly),
such that each individual has an equal chance of being chosen.
In practice, a complete list may not be available and alternative
approaches such as cluster sampling can be used (these more
complicated designs are not described here). The important points
are that selection of individuals uses random sampling and that the
sample obtained is representative of a target population.
Complications
Surveys usually do not have a separate control or comparison group,
so studies that have them are not surveys. However, in the analy-
sis of surveys one subgroup in the sample may be compared against
another (e.g. men versus women, or old versus young). Comparisons
are being made, but there is no sense in which one group is acting as
a control to another group. All the individuals have been selected at
the same time and an internal comparison is made.
Terms of identification
Use of the term survey in a paper should identify the method,
but sometimes the term is used for what is really a cohort study.
Cross-sectional is a helpful term because it is seldom used with any
other research method. Prevalence, the frequency of something in
a sample, also suggests that a study is a survey. The terms sample
Cohort studies 9
and random sample are unhelpful because they often appear in the
description of the other research designs. The terms simple, cluster,
or systematic can be used with the word sampling to describe differ-
ent ways of drawing a sample, e.g. cluster sampling. These terms are
seldom used with the other research designs. The phrase stratified
sampling is also used in surveys, but the word stratified can also be
used in randomised controlled trials (RCTs).
Cohort studies
Cohort studies are used to find out what happens to study partic-
ipants over time. It is the method of choice for studying disease
prognosis, or for investigating the consequences of exposure to
potentially harmful agents. For example, studies could investigate
how long patients with acute low back pain take to recover, or
how many people who smoke subsequently develop lung cancer.
Whatever the topic, a group of individuals is identified and followed
up to see what events befall them. Most commonly the aim is to
determine whether exposure to a potentially noxious substance
leads to an increased risk of a disease. Sometimes the interest is in
whether potentially beneficial substances, such as dietary vitamins
or fish oils, reduce the risk of disease.
Essential features
The defining characteristic of cohort studies is the element of time: in
cohort studies time flows forwards. A set of individuals is identified at
one point in time and followed up to a later time to ascertain what has
happened. These studies are called prospective cohort studies. When
studying the impact of some exposure, cohort studies often have a
comparison or control group. The controls are usually identified at
around the same time and followed for the same length of time. This
type of cohort study is called a concurrent cohort study.
Many cohort studies do not have a control group; instead they
can make internal comparisons. For example, a cohort could recruit
10 Chapter 3 Identifying the research design
a large sample from the general population and identify who smoked
and who did not. The whole sample would be followed up for several
years to determine whether lung cancer occurs more frequently in
smokers than in non-smokers.
Complications
Some cohort studies identify the group from some time in the past
and follow them up to the present. These studies might at first appear
to be looking backwards in time, but they are not. Historical records
are used, and time flows forwards from the point at which the indi-
viduals are identified. This type of design is usually called a retrospec-
tive cohort study. (Note the term historical cohort study is used when
the exposed group is recruited from one period and the comparison
group comes from an earlier period.)
Terms of identification
The terms prospective and longitudinal suggest a cohort study,
although these terms are also used in clinical trials. The term
retrospective is used for one type of cohort study, but is also used
with case–control studies.
Case–control studies
Essential features
Case–control studies look backwards in time from some event
(e.g. the diagnosis of breast cancer or failing to attend a clinic)
to try to identify factors in the past that might explain why that
event occurred. The direction of time is crucial for distinguishing
between cohort studies and case–control studies: cohort studies look
forwards; case–control studies backwards.
Complications
The use of a control group is not a defining characteristic, since RCTs
always have one, and cohort studies often do.
Terms of identification
Several terms are used for this type of study including: case–control,
case-referent, case-comparator, and case-comparison. Because the
method looks backwards in time it is sometimes called a retrospective
study, but this term can be used with cohort studies.
RCTs
The RCT should be the easiest method to identify. This design is used
to test whether one health care intervention is superior to another.
RCTs are most often used to test drugs, but they can be used to inves-
tigate many different types of health care interventions: surgery,
vaccination, anti-pressure sore mattresses, and health education.
RCTs often compare a new treatment against the currently accepted
best treatment. If there is no existing treatment, the new one is com-
pared against a placebo (an inert substance or a dummy procedure).
12 Chapter 3 Identifying the research design
Essential features
RCTs are always concerned with effectiveness. The key element of
this design is that patients are randomly allocated to receive a new
treatment or to the conventional one (or a placebo). The outcome of
the new treatment is compared with that of the conventional one,
identifying which is superior. RCTs are also concerned with the
side effects of treatments. Most RCTs compare two treatments, but
sometimes more than two treatments can be investigated. This adds
complexity to the conduct and analysis of the study, although the
resulting study is a valid RCT.
Complications
The phrase clinical trial is often used as shorthand for an RCT.
However, clinical trial can refer to studies in which patients are
allocated treatment in a non-random way (non-randomised studies).
For example, cohort studies can be used to assess effectiveness: a
group of treated patients and an independent control group are
followed up to see which group gains most benefit.
Terms of identification
The term randomisation almost always identifies an RCT, as does the
equivalent phrase random allocation. (Note that the term random
selection may refer to a survey.) The terms blinding, placebo, effec-
tiveness, efficacy, and evaluation, or phrases like assess the value of or
improve the outcome, can be used in both RCTs and non-randomised
studies.
Essential features
The essential feature of this design is that the treatment patients
receive is selected by the doctors who are responsible for their
care, based on an assessment of their specific clinical circum-
stances. Rather than being randomised to treatment groups, clinical
judgement is used to decide which treatment will be best for each
patient. As a result, the patients given one treatment may differ
systematically from those given the other treatment. This is the
major weakness of the research design, as the two groups of patients
will be different at the start of the study (i.e. before they receive their
treatment).
Complications
A special type of cohort treatment study is the quasi-randomised
study. In this design patients are assigned by the researchers to
treatment groups using a non-random method such as date of
clinic appointment (assignment by alternate days) or date of birth
14 Chapter 3 Identifying the research design
Terms of identification
There are no specific terms which identify this research design.
The terms concurrent cohort study and historical cohort study could
refer to this design, but they could also refer to conventional cohort
studies (those which do not evaluate the effectiveness of treatments).
The term non-randomised study is often used for this type of study,
although that label refers to a group of research designs which
include case–control studies, surveys, interrupted time series, and
case series.
Systematic reviews
Essential features
Systematic reviews search electronic databases of research studies,
such as MEDLINE, EMBASE, and CINAHL, to locate published
studies, using carefully chosen combinations of key terms. Papers are
carefully screened to identify the relevant ones. The chosen papers
are commonly referred to as the primary studies. Key data items,
such as effect size, standard deviation, and sample size, are extracted
from each study. These data are usually, but not always, combined
to provide an overall estimate of effect size using meta-analysis.
Systematic reviews 15
Complications
There are no complications. The design of a systematic review differs
substantially from all other types of study, so that an inspection of the
methods used should identify it.
Terms of identification
Either of the terms systematic review or meta-analysis identifies the
design. If there is doubt, then the use of a search strategy should
provide confirmation. The terms review and narrative review can
refer to a systematic review or to a study with a less complete collec-
tion of primary studies. An overview usually indicates a collection of
systematic reviews, but it can be used for a set of primary studies.
CHAPTER 4
Interpreting the Results
16
The effect size 17
In most quantitative research designs the key item is the effect size,
the observed difference between two groups. For example, cohort
studies compare the frequencies of the outcomes in exposed and
non-exposed groups, and clinical trials do so for the treated and
the control groups. Case–control studies identify the factor(s) that
distinguish cases from controls. What matters is the magnitude
of the effect size, how much the two groups differ, with large
differences usually being more important than small ones. Several
measures are used to quantify the differences between groups, and
these are described in the text that follows.
Relative risks can also be less than 1.0. For exposures such as reg-
ular aerobic exercise, which decrease the frequency of heart disease,
the relative risk could be 0.8, corresponding to a 20% reduction in
risk. In clinical trials the interest lies in whether the new treatment
reduces the frequency of an outcome compared to the control. Thus,
a relative risk of 0.8 indicates that the new treatment was slightly bet-
ter than the control treatment, whereas one of 0.2 would suggest it
was much better and 0.1 would show it was very much better. In con-
trast, a relative risk of 1.2 would mean that the treatment could be
harmful.
reduce the rate to 10%, preventing many more deaths. This example
shows that the potential impact of the relative risk depends on the
mortality rate of the disease.
All study results are subject to the play of chance. Suppose when
one study was completed, a second identical one was carried out.
It is very likely that the effect sizes from the two studies would
be similar but not identical. (The characteristics of the patients
included might differ, and the data collected could contain different
measurement errors.) If the study could be replicated hundreds of
times, then taking an average of all the effect sizes would remove
the impact of the play of chance. In effect, the average would be very
close to the true value. Many of the individual effect sizes will be
close to the average value, but by chance a few will be far away from
it. Thus, when a study produces an interesting finding we need to
know whether it could be real or just due to the play of chance. This
involves probability and statistical testing, which sound difficult but
are fairly straightforward.
Probability
The probability of throwing a six (with a fair six-sided dice) is one
in six. The probability of a single ticket winning the national lottery
20 Chapter 4 Interpreting the results
1
Technical note. All statistical tests make assumptions about the nature of the
data being analysed. Commonly these are that the data points are independent
and that they follow a defined distribution, such as the normal distribution.
The interpretation of statistical tests and p-values requires that these assump-
tions are met. Published papers generally do not provide sufficient information
to assess the validity of the assumptions, leaving no option but to take it on trust
that the statistical tests are being used appropriately.
22 Chapter 4 Interpreting the results
Confidence intervals
Because of the play of chance, research studies only provide an esti-
mate of the true effect size. With a large study the estimate should be
close to the true value, but it is unlikely to be identical to it. The con-
fidence interval indicates a range within which the true value might
lie. Conventionally the 95% confidence interval is used: it shows the
range within which we are 95% sure that the true size of effect might
lie. This can be helpful when deciding whether a treatment is clini-
cally important. For example, a relative risk of 0.4 might have a 95%
confidence interval 0.3–0.55. This shows that the true value is most
likely in the narrow range 0.3–0.55. However, if the same relative risk
had a confidence interval 0.05–0.95, there is considerable uncertainty
about what the true value might be. The confidence interval conveys
more useful information than p-values.
Bias
Bias is the bane of medical research. It occurs when the observed
effect size differs from the true value because of systematic flaws
in the design or conduct of a study. Unlike random chance, which
sometimes pushes the effect size up, and sometimes down, bias
consistently pushes it in one direction. The difference between
random and systematic errors can be illustrated by considering a
digital thermometer that makes errors. If it produces random errors,
then some patients will have too high a reading, and for others it
will be too low. But when calculating the average for a group of
patients, the falsely high and low readings will tend to cancel each
other out, so the group average will be close to the true value. If the
errors are systematic, either high or low, then the group average will
be consistently pushed in one direction.
Random errors become important when comparing two groups.
Usually they bias the effect size towards the null (i.e. towards no dif-
ference between the groups); the effect appears smaller than it really
Factors that distort the effect size 23
Confounding
Confounding occurs when part, or all, of the observed associa-
tion between two variables is due to the action of a third factor.
A well-known example of this is the relationship between birth order
and Down’s syndrome. Studies show that first- and second-born
children have a much lower risk of the disease than children further
down the birth order. In fact, the relationship is due to the age of
the mother, as women having a third or fourth child will usually be
older than mothers having a first or second child. Older mothers
are at much higher risk, even if they are having their first child.
Similarly, the association between alcohol consumption and lung
cancer is due to confounding by smoking. Smokers on average drink
more, and it is smoking that causes lung cancer.
Confounding is a common feature of surveys, case–control
studies, and cohort studies, and even RCTs can be affected. It
occurs because many aspects of human health and behaviour are
interrelated. For example, with increasing age blood pressure tends
to rise, and older people may need glasses to help them read. This
does not mean that hypertension causes difficulties in reading.
Instead, both are a consequence of ageing. Reducing the impact of
confounding is one of the major challenges in medical research.
Confounding is a particular problem for modest relative
risks in the range 0.5–2.0. Research has shown that such effect
sizes could easily be produced by confounding. In contrast, large
24 Chapter 4 Interpreting the results
Jimmy Herf’s legs were tired; he had been walking all afternoon.
He sat down on a bench beside the Aquarium and looked out over
the water. The fresh September wind gave a glint of steel to the little
crisp waves of the harbor and to the slateblue smutted sky. A big
white steamer with a yellow funnel was passing in front of the statue
of Liberty. The smoke from the tug at the bow came out sharply
scalloped like paper. In spite of the encumbering wharfhouses the
end of Manhattan seemed to him like the prow of a barge pushing
slowly and evenly down the harbor. Gulls wheeled and cried. He got
to his feet with a jerk. “Oh hell I’ve got to do something.”
He stood a second with tense muscles balanced on the balls of
his feet. The ragged man looking at the photogravures of a Sunday
paper had a face he had seen before. “Hello,” he said vaguely. “I
knew who you were all along,” said the man without holding out his
hand. “You’re Lily Herf’s boy.... I thought you werent going to speak
to me.... No reason why you should.”
“Oh of course you must be Cousin Joe Harland.... I’m awfully glad
to see you.... I’ve often wondered about you.”
“Wondered what?”
“Oh I dunno ... funny you never think of your relatives as being
people like yourself, do you?” Herf sat down in the seat again. “Will
you have a cigarette.... It’s only a Camel.”
“Well I dont mind if I do.... What’s your business Jimmy? You dont
mind if I call you that do you?” Jimmy Herf lit a match; it went out, lit
another and held it for Harland. “That’s the first tobacco I’ve had in a
week ... Thank you.”
Jimmy glanced at the man beside him. The long hollow of his gray
cheek made a caret with the deep crease that came from the end of
his mouth. “You think I’m pretty much of a wreck dont you?” spat
Harland. “You’re sorry you sat down aint you? You’re sorry you had a
mother who brought you up a gentleman instead of a cad like the
rest of ’em....”
“Why I’ve got a job as a reporter on the Times ... a hellish rotten
job and I’m sick of it,” said Jimmy, drawling out his words.
“Dont talk like that Jimmy, you’re too young.... You’ll never get
anywhere with that attitude.”
“Well suppose I dont want to get anywhere.”
“Poor dear Lily was so proud of you.... She wanted you to be a
great man, she was so ambitious for you.... You dont want to forget
your mother Jimmy. She was the only friend I had in the whole damn
family.”
Jimmy laughed. “I didnt say I wasnt ambitious.”
“For God’s sake, for your dear mother’s sake be careful what you
do. You’re just starting out in life ... everything’ll depend on the next
couple of years. Look at me.”
“Well the Wizard of Wall Street made a pretty good thing of it I’ll
say.... No it’s just that I dont like to take all the stuff you have to take
from people in this goddam town. I’m sick of playing up to a lot of
desk men I dont respect.... What are you doing Cousin Joe?”
“Don’t ask me....”
“Look, do you see that boat with the red funnels? She’s French.
Look, they are pulling the canvas off the gun on her stern.... I want to
go to the war.... The only trouble is I’m very poor at wrangling
things.”
Harland was gnawing his upper lip; after a silence he burst out in
a hoarse broken voice. “Jimmy I’m going to ask you to do something
for Lily’s sake.... Er ... have you any ... er ... any change with you?
By a rather unfortunate ... coincidence I have not eaten very well for
the last two or three days.... I’m a little weak, do you understand?”
“Why yes I was just going to suggest that we go have a cup of
coffee or tea or something.... I know a fine Syrian restaurant on
Washington street.”
“Come along then,” said Harland, getting up stiffly. “You’re sure
you don’t mind being seen with a scarecrow like this?”
The newspaper fell out of his hand. Jimmy stooped to pick it up. A
face made out of modulated brown blurs gave him a twinge as if
something had touched a nerve in a tooth. No it wasnt, she doesnt
look like that, yes Talented Young Actress Scores Hit in the
Zinnia Girl....
“Thanks, dont bother, I found it there,” said Harland. Jimmy
dropped the paper; she fell face down.
“Pretty rotten photographs they have dont they?”
“It passes the time to look at them, I like to keep up with what’s
going on in New York a little bit.... A cat may look at a king you know,
a cat may look at a king.”
“Oh I just meant that they were badly taken.”
VII. Rollercoaster
T
he leaden twilight weighs on the dry
limbs of an old man walking towards
Broadway. Round the Nedick’s stand at
the corner something clicks in his eyes.
Broken doll in the ranks of varnished
articulated dolls he plods up with drooping
head into the seethe and throb into the
furnace of beaded lettercut light. “I
remember when it was all meadows,” he
grumbles to the little boy.
L
ouis Expresso Association, the red letters on the placard jig
before Stan’s eyes. Annual Dance. Young men and girls going
in. Two by two the elephant And the kangaroo. The boom and
jangle of an orchestra seeping out through the swinging doors of the
hall. Outside it is raining. One more river, O there’s one more river to
cross. He straightens the lapels of his coat, arranges his mouth
soberly, pays two dollars and goes into a big resounding hall hung
with red white and blue bunting. Reeling, so he leans for a while
against the wall. One more river ... The dancefloor full of jogging
couples rolls like the deck of a ship. The bar is more stable. “Gus
McNiel’s here,” everybody’s saying “Good old Gus.” Big hands slap
broad backs, mouths roar black in red faces. Glasses rise and tip
glinting, rise and tip in a dance. A husky beetfaced man with deepset
eyes and curly hair limps through the bar leaning on a stick. “How’s a
boy Gus?”
“Yay dere’s de chief.”
“Good for old man McNiel come at last.”
“Howde do Mr. McNiel?” The bar quiets down.
Gus McNiel waves his stick in the air. “Attaboy fellers, have a
good time.... Burke ole man set the company up to a drink on me.”
“Dere’s Father Mulvaney wid him too. Good for Father Mulvaney....
He’s a prince that feller is.”
For he’s a jolly good fellow
That nobody can deny ...
Broad backs deferentially hunched follow the slowly pacing group
out among the dancers. O the big baboon by the light of the moon is
combing his auburn hair. “Wont you dance, please?” The girl turns a
white shoulder and walks off.
I am a bachelor and I live all alone
And I work at the weaver’s trade....
Stan finds himself singing at his own face in a mirror. One of his
eyebrows is joining his hair, the other’s an eyelash.... “No I’m not
bejases I’m a married man.... Fight any man who says I’m not a
married man and a citizen of City of New York, County of New York,
State of New York....” He’s standing on a chair making a speech,
banging his fist into his hand. “Friends Roooomans and countrymen,
lend me five bucks.... We come to muzzle Cæsar not to shaaaave
him.... According to the Constitution of the City of New York, County
of New York, State of New York and duly attested and subscribed
before a district attorney according to the provisions of the act of July
13th 1888.... To hell with the Pope.”
“Hey quit dat.” “Fellers lets trow dis guy out.... He aint one o de
boys.... Dunno how he got in here. He’s drunk as a pissant.” Stan
jumps with his eyes closed into a thicket of fists. He’s slammed in the
eye, in the jaw, shoots like out of a gun out into the drizzling cool
silent street. Ha ha ha.
For I am a bachelor and I live all alone
And there’s one more river to cross
One more river to Jordan
One more river to cross ...
It was blowing cold in his face and he was sitting on the front of a
ferryboat when he came to. His teeth were chattering, he was
shivering ... “I’m having DT’s. Who am I? Where am I? City of New
York, State of New York.... Stanwood Emery age twentytwo
occupation student.... Pearline Anderson twentyone occupation
actress. To hell with her. Gosh I’ve got fortynine dollars and eight
cents and where the hell have I been? And nobody rolled me. Why I
havent got the DT’s at all. I feel fine, only a little delicate. All I need’s
a little drink, dont you? Hello, I thought there was somebody here. I
guess I’d better shut up.”
Fortynine dollars ahanging on the wall
Fortynine dollars ahanging on the wall
Across the zinc water the tall walls, the birchlike cluster of
downtown buildings shimmered up the rosy morning like a sound of
horns through a chocolatebrown haze. As the boat drew near the
buildings densened to a granite mountain split with knifecut canyons.
The ferry passed close to a tubby steamer that rode at anchor listing
towards Stan so that he could see all the decks. An Ellis Island tug
was alongside. A stale smell came from the decks packed with
upturned faces like a load of melons. Three gulls wheeled
complaining. A gull soared in a spiral, white wings caught the sun,
the gull skimmed motionless in whitegold light. The rim of the sun
had risen above the plumcolored band of clouds behind East New
York. A million windows flashed with light. A rasp and a humming
came from the city.
The animals went in two by two
The elephant and the kangaroo
There’s one more river to Jordan
One more river to cross
In the whitening light tinfoil gulls wheeled above broken boxes,
spoiled cabbageheads, orangerinds heaving slowly between the
splintered plank walls, the green spumed under the round bow as
the ferry skidding on the tide, gulped the broken water, crashed, slid,
settled slowly into the slip. Handwinches whirled with jingle of chains,
gates folded upward. Stan stepped across the crack, staggered up
the manuresmelling wooden tunnel of the ferryhouse out into the
sunny glass and benches of the Battery. He sat down on a bench,
clasped his hands round his knees to keep them from shaking so.
His mind went on jingling like a mechanical piano.
With bells on her fingers and rings on her toes
Shall ride a white lady upon a great horse
And she shall make mischief wherever she goes ...
There was Babylon and Nineveh, they were built of brick. Athens
was goldmarble columns. Rome was held up on broad arches of
rubble. In Constantinople the minarets flame like great candles round
the Golden Horn.... O there’s one more river to cross. Steel glass,
tile, concrete will be the materials of the skyscrapers. Crammed on
the narrow island the millionwindowed buildings will jut, glittering
pyramid on pyramid, white cloudsheads piled above a thunderstorm
...
And it rained forty days and it rained forty nights
And it didn’t stop till Christmas
And the only man who survived the flood
Was longlegged Jack of the Isthmus....
Kerist I wish I was a skyscraper.
The lock spun round in a circle to keep out the key. Dexterously
Stan bided his time and caught it. He shot headlong through the
open door and down the long hall shouting Pearline into the
livingroom. It smelled funny, Pearline’s smell, to hell with it. He
picked up a chair; the chair wanted to fly, it swung round his head
and crashed into the window, the glass shivered and tinkled. He
looked out through the window. The street stood up on end. A
hookandladder and a fire engine were climbing it licketysplit trailing a
droning sirenshriek. Fire fire, pour on water, Scotland’s burning. A
thousand dollar fire, a hundredthousand dollar fire, a million dollar
fire. Skyscrapers go up like flames, in flames, flames. He spun back
into the room. The table turned a somersault. The chinacloset
jumped on the table. Oak chairs climbed on top to the gas jet. Pour
on water, Scotland’s burning. Don’t like the smell in this place in the
City of New York, County of New York, State of New York. He lay on
his back on the floor of the revolving kitchen and laughed and
laughed. The only man who survived the flood rode a great lady on a
white horse. Up in flames, up, up. Kerosene whispered a
greasyfaced can in the corner of the kitchen. Pour on water. He
stood swaying on the crackling upside down chairs on the upside
down table. The kerosene licked him with a white cold tongue. He
pitched, grabbed the gasjet, the gasjet gave way, he lay in a puddle
on his back striking matches, wet wouldn’t light. A match spluttered,
lit; he held the flame carefully between his hands.
A
man is shouting from a soapbox at
Second Avenue and Houston in front of
the Cosmopolitan Cafè: “... these fellers,
men ... wageslaves like I was ... are sittin on
your chest ... they’re takin the food outen
your mouths. Where’s all the pretty girls I
used to see walkin up and down the
bullevard? Look for em in the uptown
cabarets.... They squeeze us dry friends ...
feller workers, slaves I’d oughter say ... they
take our work and our ideers and our
women.... They build their Plaza Hotels and
their millionaire’s clubs and their million
dollar theayters and their battleships and
what do they leave us?... They leave us
shopsickness an the rickets and a lot of dirty
streets full of garbage cans.... You look pale
you fellers.... You need blood.... Why dont
you get some blood in your veins?... Back in
Russia the poor people ... not so much
poorer’n we are ... believe in wampires,
things come suck your blood at night....
That’s what Capitalism is, a wampire that
sucks your blood ... day ... and ... night.”
It is beginning to snow. The flakes are
giltedged where they pass the streetlamp.
Through the plate glass the Cosmopolitan
Cafè full of blue and green opal rifts of
smoke looks like a muddy aquarium; faces
blob whitely round the tables like illassorted
fishes. Umbrellas begin to bob in clusters up
the snowmottled street. The orator turns up
his collar and walks briskly east along
Houston, holding the muddy soapbox away
from his trousers.
She stood with her arm in the arm of Harry Goldweiser’s dinner
jacket looking out over the parapet of the roofgarden. Below them
the Park lay twinkling with occasional lights, streaked with nebular
blur like a fallen sky. From behind them came gusts of a tango,
inklings of voices, shuffle of feet on a dancefloor. Ellen felt a stiff
castiron figure in her metalgreen evening dress.
“Ah but Boirnhardt, Rachel, Duse, Mrs. Siddons.... No Elaine I’m
tellin you, d’you understand? There’s no art like the stage that soars
so high moldin the passions of men.... If I could only do what I
wanted we’d be the greatest people in the world. You’d be the
greatest actress.... I’d be the great producer, the unseen builder,
d’you understand? But the public dont want art, the people of this
country wont let you do anythin for em. All they want’s a detective
melodrama or a rotten French farce with the kick left out or a lot of