Coagulase negative staphylococcal infections.

SIR,-Ofcourse Dr Fowler is right! He has made a set of observations which supports a concept which is "an exceedingly important one" (25 May, p 1555). The nitpicking and carping criticisms of your referees (including your statistician) are directed, firstly, at the validity of the observations (not enough cases, etc) and, secondly, at the links in the chain leading from the observations to the concept. It is clear that other workers should take up the challenge to see if they can repeat the observations. They can do this only if the paper is published and given wide circulation. Whether the conclusions that Dr Fowler and Dr Dean draw are acceptable (if the observations are confirmed) then becomes a matter for debate among endocrinologists and others. Part of this debate appears to be about the concept and nature of hypothyroidism. From the references Drs Fowler and Dean quote they seem to be more in the "mainstream" than your first referee. The problem is, however, deeper than the fate of one particular paper. It concerns the format of presentation of a "scientific paper" with a formal methodology (a foul, though fashionable, word) of: abstract, methods, materials, results, discussion, conclusion, and references. This pattern of presentation has become a ritual and, like all rituals, frequently meaningless. When a writer, at editorial behest, tries to be succinct and omits details of methods, etc, he is accused of "woolly science. " The referees' scrutiny of "methods and materials" is clearly shown in the present papers to afford unlimited Catch 22 blocking opportunities. But if a writer fails or refuses to conform to this pattern, his paper becomes incapable of being recognised as "scientific" and is rejected. An eminent neuropsychiatrist (Oliver Sacks) now publishes his contributions to medical literature in the New, York Review ofBooks rather than the medical journals for this reason; his writings are "literature" rather than "science" (the two apparently being incompatible in the minds of editors of medical journals). Or, at best, they are dismissed as "anecdotal" and therefore unworthy of critical attention, though possibly deserving of a letter in the Lancet. (That seems to putyou in your place, I should think.) One should point out here that it is the anecdote which is the starting point for the seminal hypothesis; it is the clinicians (who see the patients) who make the initial clinical observations to create the anecdote. Not enough cases to make a reputable scientific paper? How many apples did Newton need to see fall? (There should be references at this point to Karl Popper and to Newton to lend a false air of intellectual reputability.) But the anecdote must be a fresh observation, not a stale retelling of old facts coupled with affirmations of incompetence and dressed up (mutton for lamb) in the acceptable format of "Lesson of the Week. " To be told what any medical student and doctor knows, that to misinject toxic substances can cause tissue damage, and to take up a page and a halfover this (Mr D A R Burd and others, 25 May, p 1579) while rejecting an article like Dr Fowler's and Dr Dean's does your judgment no credit. Moreover, your peer reviewer (no radiologist, obviously) who accepted the article failed to point out that the authors drew the wrong lessons from the incident: the only point to be made is "Never trust the other fellow's Venflon. " And what is the question mark doing at the end of the title, "an avoidable iatrogenic disaster? "? Do the authors think that perhaps it wasn't avoidable? Really! I suggest that you and your authors need a refresher course in the contents of "Pseuds Corner" in Pnrvate Eye. As Harry Truman said in another context, "If you can't give intravenous injections, stay out of the x ray department. " RAPHAEL EBAN