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Title Pages

Exercises in Epidemiology: Applying Principles

and Methods
Noel S. Weiss

Print publication date: 2016

Print ISBN-13: 9780190651510
Published to Oxford Scholarship Online: December 2016
DOI: 10.1093/acprof:oso/9780190651510.001.0001

Title Pages
(p.i) Exercises in Epidemiology (p.ii)

(p.iii) Exercises in Epidemiology

(p.ix) Exercises in Epidemiology (p.x)

(p.iv)

Oxford University Press is a department of the University of Oxford.

It furthers
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© Oxford University Press 2017

First Edition published in 2012

Second Edition published in 2017

All rights reserved. No part of this publication may be reproduced,

stored in

Page 1 of 3
Title Pages

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You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-in-Publication Data

Names: Weiss, Noel S., 1941– author.
Title: Exercises in epidemiology : applying principles and methods /
Noel S. Weiss.
Description: Second edition. | Oxford ; New York : Oxford University
Press, [2017] |
Includes bibliographical references.
Identifiers: LCCN 2016022295 (print) | LCCN 2016022989 (ebook) |
ISBN 9780190651510 (pbk. : alk. paper) | ISBN 9780190651527 () |
ISBN 9780190651534 ()
Subjects: | MESH: Epidemiologic Methods | Problems and Exercises
Classification: LCC RA652.7 (print) | LCC RA652.7 (ebook) | NLM
WA 18.2 |
DDC 614.4—dc23
LC record available at https://lccn.loc.gov/2016022295

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Title Pages

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Introduction

Exercises in Epidemiology: Applying Principles

and Methods
Noel S. Weiss

Print publication date: 2016

Print ISBN-13: 9780190651510
Published to Oxford Scholarship Online: December 2016
DOI: 10.1093/acprof:oso/9780190651510.001.0001

(p.vii) Introduction
Noel S. Weiss

There are a lot of texts that deal with the principles and methods of
epidemiology. I’ve been a coauthor of one of these myself. All of the texts, to a
greater or lesser extent, provide examples of real or hypothetical epidemiologic
studies to illustrate a given principle or method. For many (probably most)
readers of these books, the examples help to solidify an understanding of the
topic at hand.

What the examples do not provide is the opportunity to consider, on one’s own,
how a particular issue ought to be dealt with, or how a particular question
should be addressed. The purpose of this book is to supplement the material
contained in the textbooks in such a way that the reader is forced to: (1) identify
situations in which the validity or accuracy of a particular design or analytic
approach may be limited; and (2) determine how that limitation might be
overcome. Such actions are just those that epidemiologists have to take when
they are planning research or are reviewing that of others.

The key word in the preceding paragraph is “supplement.” The present book
cannot stand alone as a means of learning (p.viii) about epidemiology, or even
as a means of being introduced to the subject. My hope is that the exercises
contained in it can extend the knowledge of students of epidemiology, and equip
them more fully to deal with the real world problems and issues that they’ll
encounter in their professional lives.

Page 1 of 2
Introduction

This is the second edition of Exercises in Epidemiology. As was the case in the
first edition, the book is organized into seven chapters, each of which contains a
set of questions and answers to those questions. In each chapter the questions
from the first edition are placed at the beginning, with the new questions to
follow. Any reader who believes a given answer is incomplete (or wrong!) is
welcome to communicate with me ([email protected]). I would very much
appreciate the feedback.

To minimize the likelihood of an ambiguous question being present in this book,

or an incomplete or incorrect answer, I enlisted the help of the following persons
to review parts of the draft manuscript: Peter Cummings, Paul Doria-Rose, Sarah
Lowry, Amanda Phipps, Gaia Pocobelli, Ali Rowhani-Rahbar, Sophie Mayer,
Barbara Harding, Alison Rustagi, and Tom Koepsell. Their contributions helped
to make the chapters of the book that you are reading better than the draft
chapters that they received from me.

Page 2 of 2
Rates and Proportions

Exercises in Epidemiology: Applying Principles

and Methods
Noel S. Weiss

Print publication date: 2016

Print ISBN-13: 9780190651510
Published to Oxford Scholarship Online: December 2016
DOI: 10.1093/acprof:oso/9780190651510.001.0001

Rates and Proportions

Noel S. Weiss

DOI:10.1093/acprof:oso/9780190651510.003.0001

Abstract and Keywords

This chapter introduces the concept of rates and proportions in epidemiology.
Students can practice what they have learned in class with 26 questions based
on real-world examples, and then use the corresponding solutions to check their
work. Examples used include work on chronic hepatitis B virus, testicular cancer
in infertile men, cancer in pediatric renal transplant recipients, childhood
survival rates in the Republic of Congo, development of cardiovascular disease
in women, increases in the incidence of residential fires, cancer rates and
advancing age.

Keywords: Proportion, rate, numerator, denominator, measurement, accuracy

EPIDEMIOLOGISTS LOVE denominators. Sometimes we divide the number of

numerator events among exposed individuals by the total number of exposed
individuals, so that we can calculate the proportion of (say) eaters of potato
salad at a picnic who were diagnosed with a Salmonella infection during the
ensuing 48 hours. At other times, we use a person-time denominator enabling us
to calculate the rate of (say) lung cancer in persons who have been employed in
a given industry. Depending on the question being addressed, we may seek to
estimate a proportion or a rate. The accuracy of that proportion or that rate will
depend on our ability to measure correctly both numerator and denominator. (p.
2) (p.3)

Question 1.1

Page 1 of 22
Rates and Proportions

A recent study observed that 1 in 20 persons with cancer later were diagnosed
with a second cancer. In the general population, the lifetime probability of being
diagnosed with cancer is considerably greater. Is this evidence of immunity
developed as a result of the first cancer? (p.4)

Answer 1.1
This is not necessarily evidence of immunity. What’s not being taken into
account is the very different denominator for each of the two groups—the
amount of person-time at risk. Among cancer patients, person-time begins to
accrue as of the date of diagnosis, typically in mid- to late life. In the general
population, person-time begins to accrue at birth. (p.5)

Question 1.2
A study on ovarian cancer observed the following pattern of histologic type and
race among its participants.

Race Type of tumor Total

Mucinous Other

Caucasian 33 (13%) 225 (87%) 258 (100%)

Asian 55 (27%) 151 (73%) 206 (100%)

The authors concluded that Asian women “had a higher incidence of mucinous
tumors” than did Caucasian women. What reservations do you have regarding
this conclusion? (p.6)

Answer 1.2
The observed proportional distribution of histologic type by race could be due to
a relatively high incidence rate of mucinous tumors in Asian women, or as well
to Asian women having a low rate of other ovarian tumors. For example, the
rates below would give rise to the numbers presented in this question:

Race Type of tumor (rate per 100,000 woman-years)

Mucinous Other Total

Caucasian 1 6.7 7.7

Asian 1 2.7 3.7

(p.7) Question 1.3

The following is excerpted from a news item in the British Medical Journal:

The clinical features of more than 1000 patients with lung cancer
presenting to 46 UK hospitals have been analyzed. The results showed that
women under 65 are particularly at risk of small cell lung cancer—34%
presented with this form of the disease compared to 18% of men.

Page 2 of 22
Rates and Proportions

Assume that: (1) the distribution of histologic types of lung cancer in the
patients under 65 years in the 46 UK hospitals accurately reflects that of all U.K.
lung cancer patients; and (2) the difference between the figure of 34% in women
and 18% in men is not due to chance. Under what circumstance could the
observed difference not be indicative of a difference in the incidence of small cell
lung cancer between U.K. men and women under 65 years? (p.8)

Answer 1.3
The proportional incidence by gender will not be an indication of the absolute
incidence if the incidence of non–small cell lung cancer is different in men and
women.

For example:

Men Women

Small cell cancers (%) 360 (18%) 340 (34%)

Other types 1640 660

Total 2000 1000

In the above example, assuming the numbers of men and women in the
population are similar to one another, the rate of small cell lung cancer by
gender is nearly identical. The disparity in the proportional incidence comes
from the disparity in the rates of lung cancer that are not of the small cell type.
(p.9)

Question 1.4
The following statement appeared in a review article:

In 1996 in the United States, a total of about 34,000 new cases of

endometrial cancer occurred, as well as approximately 6,000 deaths from
this disease. The case-fatality is approximately 28%.

a. Assuming that the data described in the first sentence are correct, why
is it unlikely that the case-fatality from endometrial cancer is truly 28%?
b. Describe a circumstance under which the data in the first sentence and
a case-fatality of 28% for endometrial cancer in U.S. women could both be
true.

(p.10)
Answer 1.4
a. If “equilibrium” exists—in other words, no change in number of cases
or case fatality over time—the case fatality among women with
endometrial cancer should be 6,000/34,000 = 18%.

Page 3 of 22
Rates and Proportions

b. The 6,000 deaths in 1996 occurred primarily in women diagnosed with

endometrial cancer prior to that year. So, if the incidence of endometrial
cancer had very recently increased to a large degree, the appropriate
denominator for the calculation of case-fatality would be a number much
smaller than 34,000 (specifically, 21,429 cases in order to generate a
case-fatality of 28%).

(p.11)
Question 1.5
Let’s say you’ve conducted a cohort study to determine some long-term
consequences of surgical treatment of patients with cataracts. For 174 patients
who underwent surgery and 103 other patients with cataracts who did not,
you’ve used records of the state department of motor vehicles to determine who
has been involved in a motor vehicle crash as a driver. From periodic interviews
with study subjects, you are able to estimate the number of miles each one has
driven during a 2-year follow-up period.

The results of the study are as follows:

Study group No. of persons No. of crashes No. of miles driven

Surgery 174 27 5,677,867

No surgery 103 23 2,569,639

Assume the two groups of patients are exactly comparable with respect to
baseline characteristics that predict automobile crash occurrence, including
driving behavior, and that no misclassification is present in the study.

a. Estimate the influence of cataract surgery on crash rate while driving.

b. Estimate the overall influence of cataract surgery on the risk of an
automobile crash, in other words, that which would include a possible
influence of the surgery on driving behavior.

Provide the rationale for your answers. (p.12)

Answer 1.5
a. The answer is the relative rate based on the number of miles driven

b. Since the number of miles driven seems to have been influenced by the
receipt of surgery, the assessment of the aggregate impact should not
consider this, and the relative risk of should be used.

(p.13)
Question 1.6

Page 4 of 22
Rates and Proportions

The following is paraphrased from an article in the British Medical Journal1:

Although the relative rate of myocardial infarction associated with

cigarette smoking is higher in women than in men, smoking may well
cause a higher rate of myocardial infraction in men who smoke than in
women who smoke.

Under what circumstance could this be true? (p.14)

Answer 1.6
It could be true if, among nonsmokers, the incidence of myocardial infarction
(MI) in men were higher than that in women. For example, assume that in a
certain age group the annual incidence of MI was 3 per 1,000 in men and 1 per
1,000 in women. Among men, a relative rate of 2 associated with smoking would
produce a rate difference of (2*3/1,000)–3/1,000 = 3/1,000 person-years. Among
women, a higher relative rate–3–would produce a rate difference that is smaller
than this: (3*1/1,000)–1/1,000 = 2/1,000 person-years. (p.15)

Question 1.7
The following is excerpted from a letter to the editor of a medical journal:

We have observed renal cell carcinomas in 6 out of 412 patients with

analgesic nephropathy (1.4%), treated over the past 12 years. The
incidence of renal cell carcinoma in the general population is 7.5 per
100,000 population per year, so the prevalence found in patients with
analgesic nephropathy is highly significant ( p <.005).

What additional information on these patients with analgesic nephropathy would

be needed in order to better assess the possibility that they are at increased risk
of renal cell carcinoma? (p.16)

Answer 1.7
At the very least, we would need the age-specific person-time at risk for the
diagnosis of cancer among participants with analgesic nephropathy. This would
permit a comparison of age-adjusted rates of renal cell carcinoma between these
patients and the general population. (p.17)

Question 1.8
The Second National Health and Nutrition Examination Survey was a cross-
sectional survey conducted from February 1976 to February 1980, with a
probability sample of 27,801 persons in the United States.

The following table presents some data obtained in the survey:

Page 5 of 22
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Rates and Proportions

Percentage of children 6 months through 4 years with a history

of eating unusual substances by selected characteristics: United
States, 1976–1980

No. Percentage with history of eating

examined unusual substances

Blood lead level in

micrograms per deciliter:

30 or more 117 16.2

20–29 503 14.1

Less than 20 1,752 5.2

Earlier studies have shown that elevated blood lead levels (30 µg/dl or higher)
are associated with slowed intellectual development in children. At issue in the
present analysis is whether eating “unusual” substances (e.g., paint) contributes
to elevated blood lead levels.

In U.S. children 6 months through 4 years of age, can you determine the
likelihood of having a blood lead level of >30 µg/dl for those with a history of
eating unusual substances relative to the likelihood for those with no such
history? If yes, what is it? If no, why not? (p.18)

Answer 1.8

History of eating unusual substances Blood lead level (microg/dl)

≥30 <30 All

Yes 19 162 181

No 98 2,093 2,191

2,372

(p.19)
Question 1.9
The following data were obtained in a very large cohort study conducted in
Korea during 1993–2002 that examined potential risk factors (including the
prevalence of hepatitis B surface antigen positivity (HbsAg+)) for mortality from
hepatocellular carcinoma (HCC).

Page 6 of 22
Rates and Proportions

No. of HCC deaths Rate per 100,000 person-years

Men

HbsAg+ 1522 405.2

HbsAg– 734 21.8

Women

HbsAg+ 37 58.4

HbsAg– 9 1.2

a. For men and women, separately, estimate the relative mortality from
HCC associated with being HbsAg+, and also the mortality difference.
b. One of the above measures of excess mortality is greater in men; the
other greater in women. How can this be?

(p.20)
Answer 1.9
a. Relative mortality
Men: 405.2/21.8 = 18.6
Women: 58.4/1.2 = 48.7

Mortality difference (per 100,000 person-years)

Men: 405.2 – 21.8 = 383.4
Women: 58.4 – 1.2 = 57.2.

b. The annual mortality from HCC, in the absence of active infection with
hepatitis B, differs greatly by sex: 21.8 per 105 for men versus 1.2 per 105
for women. Thus, an absolute increase in mortality of 57.2 per 105
experienced by Korean women is very large in relative terms (relative
mortality = 48.7). In men, the larger absolute mortality difference (383.4
per 105) is not nearly so large on a ratio scale, since it is superimposed
not on a “baseline” mortality rate of 1.2 per 105, but on the higher male
“baseline” rate of 21.8 per 105.

(p.21)
Question 1.10
Black men in the United States have a substantially higher incidence of prostate
cancer than U.S. white men. Let’s say there’s a variant of the androgen receptor
gene that’s more common in black than white men in the United States—50%
versus 30%—that is also associated with a doubling of incidence of prostate
cancer in American men of either race.

What would be the relative incidence of prostate cancer, black versus white
American men, if the genetic marker were the sole risk factor for this disease
that differed between the two races? (p.22)

Page 7 of 22
Rates and Proportions

Answer 1.10
If x = incidence of prostate cancer in men without the variant genotype, the
incidence of prostate cancer in white men would be a weighted average of the
incidence in the 70% of men without the variant genotype and the 30% who have
it: 7x + .3(2x) = 1.3x. The incidence in black men would be .5x + .5(2x) = 1.5x,
because half have the variant genotype and half do not. If, in terms of prostate
cancer risk, white and black men were identical save for the prevalence of this
genotype, black men would have an incidence that was 1.5x/1.3x = 1.15 times
that of white men. (p.23)

Question 1.11
You read a magazine article in which a medical columnist has expressed concern
that the mean age at which colorectal cancer is diagnosed among Americans
who smoke cigarettes and consume alcohol is lower than among their fellow
citizens who neither smoke nor drink. Assume that the age distribution is the
same between Americans who smoke and drink and those who do not. Must it be
true that, among relatively young American adults, the incidence of colorectal
cancer is higher in cigarette smokers/alcohol drinkers than in other persons? If
yes, why? If not, why not? (p.24)

Answer 1.11
No. For example, if among older persons the incidence of colorectal cancer were
relatively low in those who smoked and consumed alcohol, with the incidence
among younger persons who smoked and consumed alcohol being the same as
that of young abstainers, the mean age of diagnosis of smokers/drinkers also
would be lower than that of abstainers. (p.25)

Question 1.12
The following statement was made in a newspaper article that sought to provide
data bearing on the efficacy of seat belts in preventing deaths that occur in
automobile crashes:

Of the 649 people who died in traffic accidents in Washington last year, 55
percent were not wearing seat belts. In those same fatal crashes, 73
percent of people who were belted in survived without serious injury.

Does this statement support the hypothesis that seat belt use saves lives?
Explain.

(p.26) Answer 1.12

Dead Alive

Belt 45% ?

No belt 55% ?

Total 100% 100%

Page 8 of 22
Rates and Proportions

The data do not bear on the hypothesis. What is needed instead is information on
the percentage of persons who survived these crashes who were unbelted. There
would be evidence of efficacy to the extent that this figure was smaller than
55%. Alternatively, one could compare the percentage of unbelted persons who
survived without serious injury to the figure of 73% for belted individuals:

Dead Alive Total

Belt 27% 73% 100%

No belt ? ? 100%

(p.27) Question 1.13

During a recent decade in the United States, the annual proportion of all women
ages 25 to 29 years who gave birth to a first child rose from .031 to .039. In this
same decade, however, the annual proportion of childless women ages 25 to 29
years who gave birth to a child fell from .114 to .092. How is it possible that
these two trends can be in opposite directions? (p.28)

Answer 1.13
The numerator for the two proportions is the same, in other words, the annual
number of 25- to 29-year-old American women who gave birth to their first child.
But the denominator for the second proportion—the number of 25- to 29-year-
old childless women—is but a part of the first denominator (all 25- to 29-year-old
women). In order for the incidence of first births to have risen overall but to
have declined among childless women, it must be true that the fraction of 25- to
29-year-old women who were childless must have risen during the decade. This
more than compensated for the declining first-birth incidence in childless
women and caused a rise in the first-birth incidence in 25- to 29-year-olds as a
whole. (p.29)

Question 1.14
The rate of suicide among American physicians, relative to the corresponding
rate in the population as a whole, varies by gender. Among men, the rate in
physicians is 1.5 times higher, whereas among women the corresponding
relative rate is 3.0. It turns out that the rate of suicide in American male and
female physicians is identical. For American men and women in general, what is
the relative rate of suicide in men compared to women? (p.30)

Answer 1.14
Pm = rate of suicide in male physicians,

Pf = rate of suicide in female physicians.

M = rate of suicide in American men

W = rate of suicide in American women

Page 9 of 22
Rates and Proportions

So, for American men in general, their rate of suicide is that of the male
physicians divided by 1.5.

Similarly, American women have but one-third the rate of suicide of female
physicians.

Now, because Pm and Pf are the same (we’ll label this rate as P),

American men, as a whole, have twice the rate of suicide as American women.
(p.31)

Question 1.15
A study of suicide among men with cancer was conducted in the United States.2
The goal of the study was to enable health professionals to “be aware of the
potential for suicide in cancer patients.” Some of the site-specific data are
presented below.

Type of No. of men with No. of Suicides per 100 men

cancer cancer suicides (95% CI)

Lung 102,940 215 0.21 (0.18–0.24)

Melanoma 19,377 46 0.24 (0.17–0.32)

Thyroid 5,339 14 0.26 (0.14–0.42)

It had been hypothesized that the risk of suicide during any given period of time
following diagnosis would be greatest for types of cancer with a poor prognosis
(e.g., lung) than types with a good prognosis (e.g., melanoma, thyroid). Do the
above data argue against this hypothesis? (Assume that the distribution of
demographic characteristics bearing on suicide occurrence is similar across the
three types of cancer.) (p.32)

Answer 1.15

Page 10 of 22
Rates and Proportions

The data do not argue against the hypothesis. The analysis fails to consider
person-time at risk. Because this is, on average, considerably greater for a man
with melanoma or thyroid cancer than for a man with lung cancer, the rate of
suicide (i.e., number of suicides divided by person-time at risk) in the latter
group must be higher than the rate for the other two groups. (p.33)

Question 1.16
In a study of oral cancer, you observe that 17% of the Hispanic cases are
younger than 40 years, as compared to 4.8% of non-Hispanic men with oral
cancer (p <.05).

Assume that the ascertainment of cases of oral cancer was equally complete in
the Hispanic and non-Hispanic men, and that the above difference was not due
to chance. Does this finding necessarily imply that in the population under study
the risk of developing oral cancer is elevated in Hispanic men under 40 years of
age compared to non-Hispanic men of similar age? Explain. (p.34)

Answer 1.16
No. The age disparity could simply be a reflection of the relatively younger age
of Hispanic males in the population under study.

For example:

Page 11 of 22
Rates and Proportions

Hispanic men Other men

Age (years) No. of cases Person-years Incidence per 100,000 No. of cases Person-years Incidence per
100,000

<40 17 100,000 17 17 100,000 17

≥40 83 100,000 83 337 406,000 83

% under 40 17% 4.8%

Page 12 of 22
Rates and Proportions

Or, beyond this, a high proportional incidence of oral cancer in younger Hispanic
men could be due to an atypically low absolute incidence in older Hispanic men.

For example:

Page 13 of 22
Rates and Proportions

Hispanic men Other men

Age (years) No. of cases Person-years Incidence per 100,000 No. of cases Person-years Incidence per
100,000

<40 17 100,000 17 17 100,000 17

≥40 83 100,000 83 337 100,000 337

% under 40 17% 4.8%

Page 14 of 22
Rates and Proportions

(p.35) Question 1.17

A population-based case-control study of Guillain-Barré syndrome (a
neurological disease) conducted in 1992–1994 in 4 states estimated the risk of
this disease to be 1.7 times greater among adults who had received influenza
vaccine in the prior 6 weeks than those who had not. The investigators also
estimated that the added risk of Guillain-Barré syndrome associated with the
receipt of influenza vaccine was about one per million persons during the first 6
weeks after vaccination.

From these data, can you calculate the 6-week incidence among adults in the 4-
state population who did not receive the vaccine? If yes, what is that incidence?
If no, why not? (p.36)

Answer 1.17
The difference of 1 per million in the 6-week incidence between persons who did
(Ie) and did not (Io) receive the vaccine is Ie – Io = 1.7Io – Io. Therefore, Io = 1/0.7
= 1.43 per million. (p.37)

Question 1.18
The incidence of stomach cancer in country X is 8.0 per 100,000 per year. The
incidence rate in nearby country Y, with a similar age-sex-race composition as
country X, is 10.0. You are concerned with explaining this difference. You know
that 5% of people in country Y drink tea containing suspected carcinogen A,
whereas nobody in country X drinks this tea. In order for this to be the sole
explanation of the difference in the incidence rates of stomach cancer between
the two countries, how strongly must carcinogen-A-tea drinking be associated
with stomach cancer? (p.38)

Answer 1.18
If all the difference were due to ingestion of carcinogen A in tea, the incidence of
stomach cancer in country Y could be described as follows:

where t = incidence in drinkers of A-containing tea

Therefore, a relative risk of 6 (associated with drinking A-containing tea) is

required for the whole of the difference in rates between the two countries to be
attributable to this exposure. (p.39)

Question 1.19

Page 15 of 22
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Rates and Proportions

During 1993–2001, men at 10 U.S. study centers were invited at random to

receive annual PSA screening for 6 years (plus annual digital rectal exams for 4
years; n = 38,343) or no intervention (n = 38,350).3 Through 10 years from the
time of randomization, there were 3,452 cases of prostate cancer diagnosed and
83 deaths from this disease in the group invited for screening, versus 2,974
cases and 75 deaths from prostate cancer among men in the control arm. The
investigators noted that, among men diagnosed with prostate cancer in the
screening and control arms of the trial, there were 312 and 225 deaths from
other causes, respectively, a difference of 87 deaths. They went on to speculate
that his latter difference “was possibly associated with over-diagnosis of
prostate cancer.”

What would be a better approach to quantifying the likelihood of death from

causes other than prostate cancer between men who were invited and those who
were not invited to be screened? (p.40)

Answer 1.19
Among men diagnosed with prostate cancer, ideally the rate of death from
causes other than prostate cancer, not simply the number of such deaths, would
be compared: that is, the number of deaths divided by the number of person-
years. Even though the sizes of the groups invited and not invited to be screened
were nearly identical, the number of men diagnosed with prostate cancer in the
former group was larger (by 16%, 3452 vs. 2974), because screening identified a
number of malignancies that otherwise would not have been diagnosed during
the follow-up period. Failure to take into account the relatively larger number of
person-years in the invited men diagnosed with prostate cancer would lead to a
falsely high mortality rate in that group.

To the extent that the age distribution of men with screen-detected prostate
cancer differed from that of men whose cancer was diagnosed for other reasons,
a valid comparison would require age adjustment as well (given the strong
association between age and mortality rates). (p.41)

Question 1.20
The following is excerpted from the Abstract of a report of a cohort study of risk
factors for hepatocellular carcinoma.

Page 16 of 22
Rates and Proportions

Chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection (OR = 9.10,
95% confidence interval [CI] = 2.10 to 39.50 and OR = 13.36, 95% CI = 4.11 to
43.45, respectively), obesity (OR = 2.13, 95% CI = 1.06 to 4.29), former or
current smoking (OR = 1.98, 95% CI = 0.90 to 4.39 and OR = 4.55, 95% CI =
1.90 to 10.91, respectively), and heavy alcohol intake (OR = 1.77, 95% CI = 0.73
to 4.27) were associated with hepatocellular carcinoma. Smoking contributed to
almost half of all hepatocellular carcinomas (47.6%), whereas 13.2% and 20.9%
were attributable to chronic HBV and HCV infection, respectively. Obesity and
heavy alcohol intake contributed 16.1% and 10.2%, respectively. Almost two-
thirds (65.7%, 95% CI = 50.6% to 79.3%) of hepatocellular carcinomas can be
accounted for by exposure to at least one of these documented risk factors.

Smoking contributed to more hepatocellular carcinomas in this cohort than

chronic HBV and HCV infections. Heavy alcohol consumption and obesity also
contributed to sizeable fractions of this disease burden. These contributions may
be underestimates because persons who took part in the study are likely to be
more health conscious than the general population.

a. The authors estimated that “smoking contributed to almost half of all

hepatocellular carcinoma (47.6%).” What measure of excess risk are they
referring to?
b. How can it be that despite the relative risks associated with hepatitis B
and C infection being so high, the percentage of hepatocellular carcinoma
attributable to these infections was smaller than that attributable to
cigarette smoking?

(p.42)
Answer 1.20
a. Population attributable risk %, that is, the percentage by which the
population’s incidence could have been reduced had no one in that
population smoked.
b. The percentage of cohort members who were cigarette smokers must
have been considerably higher than the percentage with either hepatitis
B or hepatitis C infection.

(p.43)
Question 1.21
The following abstract (slightly modified) appeared in the Journal of Urology.

Purpose: We determined the standardized incidence ratio of testicular cancer

in infertile men presenting with an abnormal semen analysis compared to the
general population.

Page 17 of 22
Rates and Proportions

Materials and Methods: More than 3,800 men presenting with infertility and
abnormal semen analysis during a 10-year period were identified. The
frequency of testicular tumors detected in these men at the time of their
infertility evaluation was compared to the incidence in race- and age-matched
controls from the general population during the same period (as reported by
the Surveillance, Epidemiology, and End Results [SEER] database).

Results: Of 3,847 men with infertility and abnormal semen analysis, 10 (0.3%)
were diagnosed with testicular tumors. The SEER database reported an
annual incidence of 10.6 cases of testicular cancer (95% CI 10.3–10.8) per
100,000 men of similar age group and racial composition during the same
period. The standardized incidence ratio of testicular cancer was 22.9 (95%
CI 22.4–23.5) when comparing our infertile group to the control population.

Conclusions: Infertile men with abnormal semen analyses have a 20-fold

greater incidence of testicular cancer compared to the general population.

What do you believe to be the principal limitation of the comparison made in this
study? Explain. (p.44)

Answer 1.21
The study compared the prevalence of testicular cancer in men with infertility
(and an abnormal semen analysis) with the annual incidence in the population at
large. Such a comparison does not permit a meaningful assessment of the
possibility of a heightened risk of testicular cancer among infertile men. (p.45)

Question 1.22
A cohort study sought to determine the incidence of cancer among American
children who had undergone renal transplantation. The transplants took place
during 1987–2009, with follow-up for cancer occurrence through the end of
2010.

Because of the differences over time in the types of immunosuppression

administered to kidney recipients during and soon after transplantation, one of
the variables investigated was transplant era. The following data were obtained:

Page 18 of 22
Rates and Proportions

Transplant Era Cancer Cases Other Recipients

# % # %

1987–1993 18 51 3595 34

1994–2000 9 26 3738 36

2001–2009 7 23 3106 30

Page 19 of 22
Rates and Proportions

A relatively higher percentage of cancer cases were transplanted during the

earliest time period (1987–1993), 51% versus 34%. (Assume that the observed
difference is not due to chance.) Nonetheless, you are reluctant to conclude from
these data that the rate of cancer truly was higher among persons who received
a transplant during those years. What is the primary reason for your reluctance?
(p.46)

Answer 1.22
The analysis does not consider person-time at risk. Almost certainly the earliest
transplant recipients have been followed the longest. The relatively higher
number of person-years they have accrued would have been responsible for this
larger proportion of cases even had their annual rate of cancer been identical to
that of later transplant cohorts. (p.47)

Question 1.23
The following is taken from a Commentary (slightly paraphrased) in the Lancet
(2012;380:1132):

“The Democratic Republic of Congo has seen its mortality rate of children
under age 5 (deaths per 1000 live births) fall from 181 in 1990 to 168 in
2011. Success? No, failure. The total number of deaths among children
under age 5 in that country has increased from 312,000 in 1990 to 465,000
in 2011, a 49% rise … Regrettably, the way we talk about child survival—
the statistical manipulation of that life into a rate—comes dangerously
close to such a deception.”

You disagree with the commentator and believe that his approach to judging
success or failure would be deceptive. Why? (p.48)

Answer 1.23
The success or failure of public health and clinical interventions to reduce
childhood mortality is gauged by utilizing the data from populations to estimate
the likelihood of death in individual children. This entails examining mortality
RATES, so as to account (in this instance) for the number of children under age
five years. A simple comparison of the number of deaths in a geographic
population between two time periods—the comparison favored by the
commentator—could be misleading due to an increase in the number of births in
that population over time. The larger number of under-five deaths in the
Democratic Republic of Congo in 2011 is entirely due to there having been more
children under age five years then than there were in 1990. (p.49)

Question 1.24
The following is paraphrased from a newspaper summary of an article published
in a medical journal.

Page 20 of 22
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ERSKINE, JOHN. Democracy and ideals: a

definition. *$1.50 (3c) Doran 304

20–11647

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the first and the last, were written while I was serving as chairman of
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in 1918 and 1919, and as educational director of the American
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express here from several angles a central conviction that we in the
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the striking fact in all our problems; that if in the future we are to
become and to remain a nation, we must collaborate for common
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character; French ideals and American; Society as a university;
Universal training for national service; University leadership. The
author is professor of English in Columbia university.
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+ Booklist 17:11 O ’20

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most fruitful service possible in these bewildering times. It might and
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fatigued. To wake it into literary life would have required an interval
of repose. For that very reason, it is the more valuable as a
document.”

+ − Review 3:94 Jl 28 ’20 170w

+ School R 28:637 O ’20 170w

“By an accurate understanding of the French character as well as

of our own, Prof. Erskine is able to make this study of Americanism
very illuminating.”

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250w

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determine the application of intelligence, and are not deflected by it
—mars their value.” N. W. Wilensky

+ − Survey 45:546 Ja 8 ’21 200w

 ERSKINE, JOHN. Kinds of poetry, and other
essays. *$1.50 Duffield 808.1
 20–12047

Poetry, the author holds, is not subject to evolution in its essence

but is an unchanging function of an unchanging life and its three
genres, the lyrical, the dramatic and the epic, are comparable to the
three eternal ways of meeting experience: “as simply a present
moment, or as a present moment in which the past is reaped, or as a
present moment in which the future is promised.” The other essays
of the volume are: The teaching of poetry; The new poetry;
Scholarship and poetry.

+ Booklist 17:21 O ’20

“Of great value to all lovers of poetry is Mr Erskine’s book. His

criticism is keen and trenchant and happily expressed in a style
peculiarly his own.” C. K. H.

+ Boston Transcript p4 O 27 ’20 490w

“When his moral prejudices are not in the way, Mr Erskine is a

sound writer.” Llewellyn Jones

+ − Freeman 2:405 Ja 5 ’21 800w

+ Ind 104:248 N 13 ’20 20w

Reviewed by W: McFee
 + N Y Evening Post p2 D 31 ’20 1700w

“One will find great pleasure in his book, but it will hardly take its
place as an important document.”

+ N Y Times p10 O 3 ’20 1050w

“They are characterized by a fine mingling of discrimination and

common sense. His breadth of view, his refusal to rest content with
mere special scholarship, gives value to his advice about the teaching
of poetry.”

+ No Am 212:572 O ’20 850w

Reviewed by L. R. Morris

+ Outlook 126:377 O 27 ’20 720w

“An uneven book in which the critical elements are decidedly

superior to the constructive ones.”

+ − Review 3:321 O 13 ’20 410w

“There is somewhat too much of that intellectual writing around a

subject which is common with persons who are afraid of the obvious,
but, on the whole, the book will awaken thought; it will not do this
the less because some of its reasoning will arouse criticism.”
 + Springf’d Republican p9a Ag 15 ’20
1100w

ERVINE, ST JOHN GREER. Foolish lovers. *$2

(1c) Macmillan

20–8447

Mr Ervine’s new book is dedicated to his mother, who asked him to

write a story without any “bad words” in it, and to Mrs J. O. Hanny,
who asked him to write a story without any “sex” in it. It is the story
of a charmingly conceited young Irishman who goes to London to
write novels and plays and comes home again to be a grocer. John’s
boyhood is spent in the home over the shop where three generations
of MacDermotts had preceded him. He grows up under the care of
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nothing, and his Uncle William, who supports the family. He goes to
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“‘The foolish lovers’ has nothing to commend it but a good

beginning. Why did he write it? Or, rather, why did he give up
writing it? Perhaps he would reply that what is not worth doing is not
worth doing well. It is a possible explanation.” K. M.

− + Ath p78 Jl 16 ’20 600w

+ Booklist 17:31 O ’20
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‘The foolish lovers’ is neither an exact nor an appealing designation
for a novel that is so full of the commonsense of life.” E. F. E.

+ Boston Transcript p10 My 22 ’20 1950w

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the ‘local coloring,’ has failed to evoke the fine, harsh, sincere reality
of the Black Northerners with whom his story deals. Prose drama is,
after all, this author’s true medium.”

+ − Cath World 112:696 F ’21 100w

Lit D p97 O 23 ’20 1850w

“John McDermott himself is not altogether credible. His exploits,

especially his wooing of Eleanor—the central thing in the book—have
none of the homely vigor and quiet truth of the Irish scenes and
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searching novel he might write about the people of Ulster. But he
deliberately cut himself off from that possibility here by the kindly
promises to be harmless which he records in his dedication.” Ludwig
Lewisohn

+ − Nation 111:74 Jl 17 ’20 500w

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remarkable a book as ‘Changing winds,’ is worthy of its author—and
to say that a book is worthy of St John Ervine is to give it high
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+ N Y Times 25:264 My 23 ’20 1200w

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suave and frank, sympathetically critical and wisely humorous
treatment of life as is found in this book. Its tone just suits the mood
of the cultivated man or woman of today who has outgrown youthful
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charm and in acuteness—the two qualities generally most worth
commending in the fiction of the day, in which hysteria is so apt to
take the place of power—‘The foolish lovers’ is preeminent.”

+ No Am 212:287 Ag ’20 660w

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gifts which have made its author’s novels notable among recent
fiction. Mr Ervine has something of Dickens’s love for people. No
more delightfully tender description of a courtship is contained in
recent fiction, nor any which so finely sets forth as that in ‘The
foolish lovers’ the unconscious humor of young love.” L. R. Morris

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somewhat diffuse, somewhat overburdened with scenes and
‘characters,’ if not, in this instance, with ‘ideas.’” H. W. Boynton

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himself on Eleanor is ably studied.”

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with the freshness and vigour which we have come to expect from his
work.”

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characteristics and political trends, and engages the reader’s close
interest in all its phases.”

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Ballyards. The characters of Uncle William and Uncle Matthew are
delightful. The success with which Mr Ervine brings out their
simplicity and nobility of character is a convincing proof of his gifts
as a novelist.”

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24 ’20 800w

ESCOUFLAIRE, RODOLPHE C. Ireland an

enemy of the allies? tr. from the French. *$2.50
Dutton 941.5

20–5757
 “M. Escouflaire’s thesis in this volume is that the Irish question so-
called is ‘an international imposture.’ In years past this French writer
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but his contact with British statesmen during the war led him to
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independent study of Ireland’s relations with England he declares
categorically that the whole Irish claim of oppression by England, so
far as the present generation is concerned, is a myth.”—R of Rs

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treatment of Irish affairs which would otherwise be merely stupidly
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present critic hates Sinn Fein and all its works as much as M.
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artillery not so far out of range.” H. L. Stewart

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R of Rs 61:556 My ’20 80w

“Accurate and spirited little book.”

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ESSEN, LÉON VAN DER. Short history of

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there the Roman Catholic has led the historian astray.”

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EVANS, CARADOC. My neighbors. *$1.75 (5c)

Harcourt
 20–5187

More stories of a Welsh rural neighborhood by the author of “My

people” and “Capel Sion.” In a prologue entitled “The Welsh people”
the author offers some explanation of the ugly and distorted aspects
of human nature that he presents. The stories are: Love and hate;
According to the pattern; The two apostles; Earthbred; For better;
Treasure and trouble; Saint David and the prophets; Joseph’s house;
Like brothers; A widow woman; Unanswered prayers; Lost treasure;
Profit and glory.

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not a little in criticism of it. But the religion which Mr Evans
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have been. But Mr Caradoc Evans’s book does not describe us. It
describes only Mr Caradoc Evans’s own soul; and it is not a pretty
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present trend one can see little chance for its development. The
stories are like rocks—impressive but barren. The preface is written
in a more flexible vein and a more ironic mood. In it the language of
the English Bible, from which Mr Evans draws, is transmuted for the
uses of his artistic intention. In the stories themselves it is employed
merely as a weapon. But his work has fierce honesty, concentration,
power. It is sanative and, within its definite limits, completely
achieved.”

+ − Nation 110:522 Ap 17 ’20 450w

 “But does he really traverse the whole stage? We cannot think so.
Where there are Goneril and Regan we cry out for a Cordelia, and Mr
Evans would, we think, have made his terrible portraits more
effective even than they are already if he had introduced more
contrast and relief into them.”

+ − Nation [London] 27:77 Ap 17 ’20 600w

“Mr Evans knows the Welsh intimately and searchingly, and his
portrayal of their daily lives, their bickerings, prayings and
aspirations is altogether ruthless and incisive.” Pierre Loving

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“The hardy reader who will persist beyond the almost

impenetrable idiom of Caradoc Evans will be richly rewarded.
Especially do we recommend the book to reformers, utopists,
spinners of millennial dreams.”

+ N Y Times 25:160 Ap 4 ’20 600w

N Y Times 25:191 Ap 18 ’20 60w
Springf’d Republican p13a My 2 ’20
320w

“He is sometimes difficult to follow, partly because the dialogue is

in English literally translated from the Welsh, and partly because the
stories are almost excessively condensed; but the subdued irony and
false simplicity are delightful, and he knows the sovereign power of
the restraint which leaves events to explain themselves without
heavy exegesis.”
 + The Times [London] Lit Sup p154 Mr 4
’20 450w

EVANS, EDWARD RADCLIFFE GARTH

RUSSELL. Keeping the seas. il *$3 Warne 940.45

20–2282

“Captain Evans saw a great deal of the Dover patrol and of all it
included. He tells his experiences, so to speak, right on end and in a
kind of chronological order. He is a witness who was there and
records what has remained in his mind of what he saw. And he had
notable things to remember; for he commanded the Broke in the
action of March, 1917, in the Straits. The war produced few such
passages of conflict as the action in the Straits. Captain Evans’
services, like those of other officers, consisted in the main of cruising
and watching. At the end he was afforded a change in the direction of
Gibraltar and the Portuguese coast.”—The Times [London] Lit Sup

+ Booklist 16:307 Je ’20

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stories which would have been the better if they had been more
carefully digested; but if the whole is rather confusing, not a little
good matter is to be found in the heap.”
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’20 1050w

EVANS, MRS ELIDA. Problem of the nervous

child. *$2.50 (3c) Dodd 136.7

20–6871

This volume comes with an introduction by Dr C. G. Jung of

Zurich who says of the author: “Mrs Evans’ knowledge of her subject
matter is based on the solid foundation of practical experience, an
experience gained in the difficult and toilsome treatment and
education of nervous children.... This book, as the reader can see on
almost every page, is the fruit of an extended work in the field of
neuroses and abnormal characters.” Its purpose is to aid parents in
the training and education of their children, not to add another “to
the already long list of textbooks explaining psychoanalytical
treatment for nervous troubles.” It does not presuppose scientific
training in the laws of human development on the part of those for
whom the book is intended and therefore avoids technical terms and
abstruse discussions as far as possible, giving only end results of
present day research and observation on the subject, with examples
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repression; Symbolic thought; The child and the adult; Mental
behaviour of the child; Defence reactions; The parent complex;
Buried emotions; Child training; Muscle erotism; The tyrant child;
Teaching of right and wrong; Self and character; Index.

+ Booklist 16:303 Je ’20

 “There are spots in the book where the all-absorbing panacea of
psycho-analytic therapy is too powerful, and she over-stresses the
environment, losing sight of the medico-psychological fact that many
defects are organically directed. The book needs a broader sensing
and interpreting of the ever present interplay between the hereditary
and environmental forces.” H. F. Coffin, M.D.

+ − Survey 44:494 Jl 3 ’20 270w

EVANS, LAWTON BRYAN. America first. il

*$2.50 Bradley, M. 973

20–16082

“Instead of being what the title might imply, the volume contains
one hundred stories from the history of America in condensed form
and written in a style that will prove interesting to the juvenile
reader. The author goes on the supposition that the nearer a story is
to the life of the child, the more eagerly it is absorbed. True stories,
he says, about our own people, about our neighbors and friends and
about our own country at large, are more interesting than true stories
of remote people and places. The stories grouped in the volume open
with ‘Leif, the lucky,’ and continue down through history to the time
when Americans made history over-seas.”—Springf’d Republican

“An excellent piece of work. The book will be a valuable

supplement to school study of our national history and it will
stimulate a healthy national pride.”

+ Ind 104:378 D 11 ’20 100w

 Outlook 126:470 N 10 ’20 40w
+ Springf’d Republican p7a N 21 ’20 180w

EVARTS, HAL GEORGE. Cross pull. *$1.90

(3½c) Knopf

20–4269

The hero of this story is Flash, a cross between wolf, coyote and
dog. Clark Moran took him as a puppy and tamed him and the dog in
him responded to kindness. To one other Flash gives his allegiance,
to Betty, the girl from the East who comes into the mountains. To
most other humans he is indifferent, but there is one he hates. The
story tells how he served his two loved ones in a crisis, and how in so
doing he took his own revenge on his enemy. In the end he settles
down as a safe and trusted house dog, but there were times when the
wild strain awakened and at those times, on still nights during the
mating moon, certain civilized suburbanites would experience a
primitive shudder at hearing the lone wolf’s call.

“Not over humanized or sentimentalized; one of the best dog

stories.”

+ Booklist 16:243 Ap ’20

“A better novel it might have been, but a better animal study it

could scarcely have been.”

+ − Boston Transcript p7 Je 23 ’20 200w

 “A story of more than ordinary interest either as an ‘animal story’
or a ‘live’ western romance.”

+ Springf’d Republican p11a Je 13 ’20

200w

EVARTS, WILLIAM MAXWELL. Arguments

and speeches: ed., with an introd., by his son
Sherman Evarts. 3v *$15 Macmillan 815

19–16299

“Mr Evarts (1818–1901) as leader of the American bar, orator, and

statesman, was one of the most conspicuous of American citizens in
the nineteenth century. This substantial collection of his public
utterances not only provides a record of his career, but an important
document for the social and political events of his day and for the
history of American oratory. He was the leading counsel for the
defendant in the impeachment trial of President Andrew Jackson in
1868; and in 1872 was counsel for the United States in the Alabama
arbitration at Geneva. He was secretary of state during President
Hayes’s administration (1877–1881) and one of the senators for New
York 1885–1891.”—The Times [London]. Lit Sup

“The editor’s introductions and comments are brief and well

chosen throughout. Taken as a whole, the volumes are a worthy
memorial to one of the influential leaders of the American bar, and of
the Republican party during a difficult period of our history.” W: A.
Robinson

+ Am Pol Sci R 14:349 My ’20 360w