To the Editor:— The recent article on pagophagia and the accompanying editorial comment (207:513, 1969;207:552, 1969) point out one of the most preplexing aspects in the study of the many forms of pica. This problem is to determine whether the associated anemia is the cause of perversion of the appetite or whether perversion of the appetite indeed causes anemia. While it is tempting to look for a direct cause and effect relationship, critical examination of the many available reports does not settle the question. We agree wholeheartedly that it would appear prudent to keep an open mind to the possibility that many factors may be operational at the same time. We have begun to reexamine our own material and premises in this area. Our original article noted an absolute incidence of 34.6% of 1,000 obstetric patients admitting to amylophagia during pregnancy (Obstet Gynec32:415, 1968). An