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L. J 1 ,~ reach the conclusion that there is no other explanation for the abortion, threatened or by habit, or where we find a arborization effect in the cervical mucus. What is t type of case ? (1) A woman who has had three succesgCve abortions as her first experiences, in the absence of genital tract abnormality, can reasonably be assumed to have a hor- mone imbalance-that is, progesterone deficiency. Ourresul's support this assumption. (2) The patient who has an abor- tion in- her first pregnancy and threatens in her second frequently has sodium chloride crystals in the cervical mucus. We use this as an indication for progesterone therapy. (3) We also use this latter method of investiga- tion in patients who threaten to abort in their first pregnancy. We have no experience in the use of vitamin E in habitual abortion, but are confident some of Dr. Sutton's large series of cases must have been deficient in progesterone. Perhaps this vitamin fortifies the corpus luteum, stimulates the luteinizing factor of the pituitary, or in some way accel- erates trophoblastic development, thereby facilitating im- plantation, but, whatever the reason, this large series should' be published so that others can study it. We wish to con- gratulate Dr. Sutton on his results and to prevail on him to give his reasons for this therapy.-We are, etc.,' Havant, Hants. JOHN FOLEY. ' Portsmouth. Hants. ARTHUR C. WILSON. REFERENCE t Relfenstein, E. C.. Ann. N.Y. Acad. Sct., 1958,'71, 762. A.I.D. Investigation Council SIR,-lfie Eugenics Society has set up an A.I.D. Investi- gation Council to consider the present status and future potentialities of A.I.D.-genetic, medical, legal, and social. The Council has in mind the maintenance of a permanent committee which will at all times have a record of all available data on A.I.D. cases done in this country, with all available medical and scientific information relevant thereto. The Council would be grateful to hear from any medical practitioner with a contribution to make towards this investigation.-We are, etc., 69. Eccleston Square, London, S.W.1. PHILIP M. BLOOM, MARGARET HADLEY JACKSON, Hon. Secretaries, A.LD. Int-estiaation Cou:uil. Protein Anabolizers SIR,-In the interesting and timely annotation on tissue building and protein anabolizers (lournal, September 27, p. 785) it is stated that :" This good effect [of testosterone therapy for bone metastases due to breast carcinoma] has been attributed to a consequent change in hormonal environment of the cancer, possibly resulting in some depression of oestrogen action by testosterone. If this is so, no good result would be expected from the use of 19- nortestosterone in this disease." Whether in fact the action of testosterone in breast cancer is due to suppression of oestrogens or not is equivocal, but I would point out that norethandrolone, in addition to its other actions, is an antagonist of oestrone-induced uterine growth in intact immature mice, with seventy times the potency of testo- sterone propionate. This effect of 17-nortestosterone obviously cannot be due to its androgen activity, as the androgen : anabolic ratio of this steroid is 1: 15, as com- pared to 1: 1 for testosterone propionate.' However, so far as I am aware, it is not yet known whether norethandrolone reduces the secretion of, or antagonizes, oestrogens in man, but adrenocortical secretion can be suppressed in man by this new steroid.'-I am, etc., Bristol. GEORGE Foss. R_FERENCES , Edgren. R. A., and Calhoun, D. W., Proc. Soc. exp. Biol. (N.Y.), 1957, 94. 537. Saunders. F. J., and Drill, V. A., ibid., 1957, 94, 646. Brooks, R. V., and Prunty, F. T. G.. 1. Endocr., 1957, 15, 385. Prevention of Lung Cancer SIR,-I disagree with the suggestion of Mr. Leslie J. Temple (Journal, October 4, p. 858) that the coroner should be notified of deaths due to carcinoma of the lung in heavy smokers. He draws a parallel between such deaths and the death of a coal-miner with pneumoconiosis or a mule-spinner with cancer of the scrotum. The latter are examples of industrial disease and as such are notifiable. There is no significant occupational or industrial link in the case of cancer of the lung, which is basically a natural disease, usually, but not invariably, asso- ciated with the habit of smoking over a period of many years. There would therefore seem to be little justification for notifying the death, and, if notified, there is no certainty that the coronerr will take further action. If, however, he does hold an inquest, he may put the following questions to the medical witness : Is it possible for a non-smoker to acquire cancer of the lung ? Is it possible to smoke 40 cigarettes a day for the whole of one's adult life and escape cancer of the lung 7 The brief answer to both questions is .".Yes," a reply, which can only add to the confusion which exists in the minds of the public on this matter. Certainly our profession should spare no effort to dis- courage a doubting public from smoking to excess and exposing themselves to the risk of cancer of the lung (and other diseases), but the coroner's court is not, I submit, the proper platform for propaganda directed to this ena.-I am, etc., Canterbury, Kent. . G. B. FORBES. SIR,-In the vexed question of the association of lung cancer and smoking, which has evoked much statistical analysis concerning the smoker and the preparations of tobacco smoked, and varying opinions as to their mean- ing, one wonders whether adequate attention has been paid to methods of igniting the tobacco. An inveterate pipe-smoker myself, I have for decades refused to use other than a match, as the vapour from a lighter spoils the aroma throughout the entire smoke. Could it not be that pipe-smokers are more free from lung cancer than cigarette-smokers because they seldom inhale the fumes from flint-ignited lighters while those who smoke cigarettes more frequently do so ? Lighter fuels consist of petrol and related substances, and, if such could be incriminated, at least a simple and rational link would be provided with the exhaust fumes of internal combustion engines, another fre- quently cited possible contributory cause.-I am, etc., London, W.1. R. R. WILLCOX. Informing the Hospital SIR,-Dr. Norman Gold's letter on the identification of tablets (Journal, October 18, p. 978) raises a host of prob- lems. They have naturally engaged the attention of the -Joint British National Formulary Committee, to which he refers and of which I am a member, but the following re- marks are entirely perSonal in an attempt to explain some of the points involved. First of all it must be realized that when B.P. preparations are mentioned in the Formulary (or prescribed by the doctor) it is bound rigidly by the provisions of the British Pharmacopoeia • itself, nor can we get away from this condition by omitting the letters B.P. if we use the same name. And the fact is that the British Pharmacopoeia Commission, I think unwisely, has set itself against any distinctive coloration of tablets, specifically stating' :° The addition of colouring or flavouring agents, except where pormitted in the monographs, is not official." And these permissions are hard to find. They seem to be limited to such things as tabs. mepyramine maleate (" anthisan "), promethazine (" phenergan "), or probantheline (" probanthine ") where the substance is only made as a proprietary preparation and where the Commission cannot coerce the maker to its predilection to un- coloured tablets, with all their associated possibilities of confusion. It is true that in a few cases-e.g., tab. butobarbitone-the N.H.S. Drug Tarijj does say "(may be coloured)," but this is strictly in- correct and, I think, ultra vires. In the same wax a chemist who

I 0 ~ ~. Nov. 1, 1958 CORRESPONDENCE frustrating though it be, we still depend entirely on what the patient tells us. For record purposes the audiometer used is a Peters fitted with its standard oscillator and providing in the cases noted an inter- rupted signal. The children mentioned in tha article had experi- enced the sensations of hearing by earphones and therefore had a basis from which to work. With the oscillator applied to the mastoid region by an assistant, the child was repeatedly asked to differentiate between hearing and feeling, and, at the frequencies and intensities indicated, the answers were definite. In every case the signals were gradually increased from the minimal intensity up to the point of hearing. Concerning the identical appearances of the audiograms noted by Dr. Fisch, it should be pointed out that since the original tests in May, 1957, repeat examinations have shown distinct variations in the curves although there remains in each the general pattern of bone conduction readings at lower intensities than air con- duction. The fact that the inner ear of the congenital deaf-mute is defective on histological examination may suggest that the initial lesion was in the cochlea, but tacit acceptance of this ignores (a) the association of deaf-mutism with congenital defects of the first visceral arch, (b) the complete absence of any recorded instance of other labyrinthine disorders in the deaf-mute child, and (c) the normal radiological appear- ance of the bony cochlea in deaf-mutism. Mr. Bauer, who also finds my arguments unconvincing (Journal, October 4, p. 588), quotes the condition of bilateral congenital atresia of the auditory meatus with malformation of the incus to show that excellent inner-ear function may exist with an abnormality of the middle ear, but this does not mean that all middle-ear anomalies will allow of excel- lent cochlear function. His suggestion that the surgeon should examine the middle ear in the congenital deaf-mute through the operating microscope is an excellent one, and, so far as I am aware, has not yet been done. Undoubtedly it is the most direct method of proving or disproving my theory of the cause of congenital deaf-mutism, and I look forward to learning the results of such an investigation.- I am, etc., Aberdeen. JOHN MCKENZIE. Imbecile Children SIR,-Dr. C. Guy Millman (Journal, October 4, p. 859) suggests that mentally defective children may die just as readily at home as in an institution, and that the high death rate which we reported in the post-admission period may therefore not be significant. He adds that one would not expect skilled nursing and medical attention to hasten the death of the children. We do know that children on our waiting-list sometimes die at home. We wished, however, to draw attention to the very high death rate in the post-admission period. The figures which we reported provide an internal control, since they show that the death rate is related to the admission of the patient to hospital. If the children die merely because they are delicate, then there is no special reason why the deaths should be concentrated in the post-admission period. There is no question of the children being acutely ill on admission to hospital. They have been on our waiting-list for up to three years, usually at least one year, and we do not admit acutely ill children-they are referred to a paedi- atric department. The problem of post-admission deaths merits further study. It is well known that there is a certain risk in admit- ting young children to hospital. In this respect mentally defective children seem to react like much younger children. We think that the excess of deaths can be partially explained on the following grounds : (1) Infection.-Very backward children have often been rather isolated prior to admission and have not mixed with other children very much. On entering a large overcrowded ward they are exposed to a very considerable battery of mixed infection, much of which is new to them. (2) Stasis.-At home most of these children are picked up, nursed, and moved a good deal by their mothers and others. BwTrSH 1103 MEDICAL JOURNAL With the very limited nursing staff available this is not possible in hospital. This is particularly important in cripples. Static pneumonia associated with inefficient cough reflex and repeated inhalation of small quantities of food is the common cause of death. (3) Change of routine and fretting.-Despite their low intelli- gence, our children have become accustomed at home to a certain diet, method of feeding, maternal attention, and so forth. Hos- pital admission means a sudden disturbance of this routine, with much reduced attention. Part of the loss of weight and other changes which so often follow admission may be attributable to this. Many of the children are manifestly miserable after admission. It is not the skilled attention which hastens their death, but rather the shortage of it.-We are etc., London, S.W.17. EVELYN B. LIND. . BRIAN H. KIRMAN. Vitamin-D-resistant Osteomalacia SIR,-In our report on " Vitamin-D-resistant Osteo- 'malacia "' we remarked upon a too ready acceptance of the theory that the basic causation of this group of disorders was simply a renal tubular defect with excessive phosphate leak (the " phosphate diabetes " of Fanconi). We quoted a paper by Dr. Alan Rose2 as an illustration. Dr. Rose has pointed out to us that he did not in his paper actually state that the sole or basic cause of the osteomalacia in his case was a primary phosphate leak, although he emphasized the occurrence of a high renal clearance of phosphate. In fairness we must agree that we all find a high phos- phate clearance in these cases, but whether this is a primary renal tubular defect or whether secondary to some other disturbance (e.g., hyperparathyroidism) is uncertain. The title of Dr. Rose's paper was " Renal Tubular Osteomalacia," which would appear to indicate a basic aetiology, although this is not specifically stated. Certainly we (Jackson and Linder) previously agreed' that a primary renal tubular de- fect provided a good explanation of the syndromes of " vita- min-D-resistant rickets and osteomalacia," but we are now less convinced, for reasons discussed in our recent paper.- I am, etc., W. P. U. JACKSON. Capetown, S. Africa. REFERENCES Jackson, W. P. t;.. Dowdle. E., and Linder. G. C., Brit. med. J., 1958, 2, 1269. ' Rose, G. A., ibid., 1956, 2, 805. ~ Jackson, W. P. U., and Linder, G. C., Quart. J. Med., 1953, 22, 133. Treatment of Habitual Abortion S1R,-Dr. R. V. Sutton's letter (Journal, October 4; p. 858) and your annotation on hormone-induced sex changes (lournal, July 26, p. 218) suggest there may now be conclu- sive evidence that progesterone therapy results in the pro- duction of some abnormal foetuses, particularly in regard to the genital tract. This is not our experience. We have recently completed a series of 50 cases using 17-a hydroxy progesterone 17N caproate (" primolut depot "). There were only two abnormalities. One baby had pyloric stenosis, sTce successfully treated, and the other was an anencephalic foetus stillborn at 29 weeks. We hope shortly to publish our results. Reifenstein' presented a comparable series to the New York Academy of Sciences on October 8, 1957. He had two abnormalities in 54 cases, neither of which involved the sex organs. Using large doses of this same hormone from the early weeks of pregnancy he had a foetal salvage rate of 69°,o in habitual abortion. In our own smaller series the salvage rate was just over 80°,11,. We also agree with Reifenstein that there does not appear to be any increase in foetal abnormalities in these cases. The average total dose of long-acting progesterone given by us to these patients was 3.375 g., and in seven cases where the therapy commenced within two weeks of the first missed period the total dose approached 5 g. There were no abnor- malities in these latter cases. What are the reasons for embarking on progesterone therapy ? We employ this method of treatment when we