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at once. " Sudden " death is regarded as sometimes, but

not always, "

unexpected "; for the purpose of notifica-tion to the coroner the consistent use of " unexpected "is recommended. The meaning of " unnatural "in relation to death is rightly said to depend onthe collateral circumstances and prevailing beliefs. Atone time the death of a prisoner from starvation, anon-violent death, was thought to be natural; and deathfrom infection may be natural or not according to theavailability of suitable antibiotics. Equating " un-natural " with " violent " is not now wholly tolerable,nor indeed is " violent " itself given a consistent mean-ing. Injuries arising from an assault are clearly violentand the case is one for the coroner; but few would

regard, say, fatal birth injuries as examples of violence,and such a case would not be the subject of an inqueston that ground alone. Happily this semantic problem is,in practice, rather academic, because a doctor or regis-trar of deaths should be able to consult with the coronerwhen in any doubt, and the coroner can decide whetherthe case is his concern.

It has long been felt that the present system of deathcertification is greatly weakened because the certifyingdoctor need not see the body after death. Provided thathe has attended the deceased during the last illness, thedoctor is empowered to certify, to the best of his know-ledge and belief, the cause of death. In the event, thedoctor may not have seen the patient for some time if achronic illness was the main complaint; his contact

with the patient may have been no more than an inquiryfrom a relative who came for a repeat of the prescription.Yet violence of some sort may be the end to a

chronic illness: either the patient or a likely beneficiarymay become impatient, and an interested relative mightfind it in his best interests to conceal from the doctorthat the illness did not end by Nature alone. Thisrisk of an entirely misleading certificate should be

stopped or at least significantly reduced. In the view ofthe B.M.A. committee, the certifying doctor shouldhave been in actual attendance within 14 days of thedeath and -the body should be seen and externallyexamined by the doctor. Even so, unnatural deathscould still pass undetected, though there remains theadditional safeguard of the inquiries made by the

registrar of deaths and his assessment of the deathcertificate. The wording on the certificate is important,and it is hoped that in future the immediate terminalclinical event, as well as antecedent disease, will beincluded.At present no statutory duty compels a doctor to

notify suitable cases to the coroner. A certain reluctanceto become directly involved in a medicolegal investiga-tion is understandable; but even a few days’ delay innotification can ruin the chances of discovering thetruth, and the sooner the coroner is informed the earlierthe many investigations can begin and the more satis-factory will be the results. The report thereforeadvises that it should become a statutory duty on adoctor or some other person (such as a nurse, an under-taker, or an embalmer, or indeed anyone whose

suspicions are aroused) to notify the coroner or the

police without delay. No matter whether the informanthas a precise knowledge of the cause of death, or

whether a certificate has already been issued, the

suspicion of violence or poison would suffice. Manyfalse alarms could certainly arise-from ignorance,spite, or worse-but these need not be a deterrent toreform.A recurring anxiety for the pathologist doing medico-

legal necropsies is unauthorised interference with bodiesbefore his examination. The committee recommendsthat the dead body should under no circumstancesbe partially or completely embalmed, and there shouldbe no plugging of the orifices until the certificateof disposal has been issued-procedures which can

make it impossible to establish poisoning or local

injuries. In general, facilities in Britain allow a satis-factory examination of a dead body before the funeral,but difficult circumstances may arise. It can, for instance,be very perplexing to find an expedient and reliableway of thoroughly investigating a death at sea, and thefinality of burial at sea, as destructive as cremation,makes the situation more serious.The pivot of the present and the proposed organisa-

tions for investigating deaths is the coroner. Manydoctors are surprised to come across the opinion that itis sufficient for a coroner to be qualified and experiencedin law only-putting them completely in thehands of his "

interpreters " of medical terms and

methods. Indeed this mistaken view may mask the

importance of having a necropsy by an experiencedmorbid anatomist with sound knowledge of medico-legal pathology. As the committee point out, thecoroner should be learned in modern medicine and law,be appointed by the Lord Chancellor, and be in everyway competent to direct, discuss, and assess all the

investigations and findings in all his cases. The Englishcoroner system offers a fair measure of protectionagainst secret homicide (to quote HAVARD 2) and unlawfulkilling, but it must be constantly maintained and

improved; for the safety of the public can depend agreat deal on the thorough investigation of deaths intheir midst.

Annotations

THE TEACHING MACHINE IN

MEDICAL EDUCATION

AFTER the stimulus given by the General MedicalCouncil in 1957, medical schools throughout the UnitedKingdom have reviewed their curricula and many haveintroduced fundamental changes. In the present atmo-sphere of experiment, new methods of teaching are beingstudied critically, and recent reports 3 4 have discussedthe possible application of teaching machines. Theseinstruments are gaining acceptance in many branches ofeducation, but their place in university and more particu-larly in medical education has still to be established.Owen and his colleagues 4 in Newcastle upon Tyne

have begun a controlled trial among final-year students2. Havard, J. D. J. The Detection of Secret Homicide. London, 1960.3. Green, E. J., Weiss, R. J. J. med. Educ. 1963, 38, 264.4. Owen, S. G., Hall, R., Waller, I. B. Postgrad. med. J. 1964, 40, 59.

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which is designed to compare machine teaching of electro-cardiography with conventional instruction and reading.As a first step an E.C.G. teaching programme containing afew hundred " frames " of illustrations, questions, andanswers was prepared and tested on 12 students, who werethen invited to complete a questionary designed to assesstheir reaction to this method of learning. All but 1 enjoyedthe course and believed that programmed learning had alimited but important place in medical education. Aftertheir comments had been carefully considered, alterationswere made which led to a more effective and efficient

programme that will be used in the main experiment. Noserious attempt was made in the preliminary study toassess the efficacy of the method, but the results of a shortobjective test in E.c.G. interpretation which each studenttook at the end of the course suggest that it is likely to bean effective instrument of teaching. Owen and his col-leagues hope that other medical teachers will be stimulatedto write programmes in their own subjects and so con-tribute to a more general assessment of the value ofprogrammed learning.Some subjects are more suitable than others for this

form of teaching: in general, those that require under-standing as opposed to memory would be suitable forprogramming. The main attraction of a programme isthat it embodies a clear sequence of learning in whichthere is a logical step-by-step development of the subject.When the information is simple and factual, a linear

programme is used. Here the learning sequence is pre-determined and fixed and does not allow alternatives. A

branching programme is more appropriate to the relativelycomplex subjects with which medical teaching is mostlyconcerned. In this more sophisticated type of programmeit is the students’ own response to multiple-choice ques-tions which determines the order of presentation ofmaterial and the rate of progress. If a wrong answer isselected then the mistake is explained, earlier facts andprinciples revised, and tests introduced before the studentis allowed to rejoin the main learning sequence. Onlythose who need additional explanation and revision arerequired to go through the

"

wrong answer " material, and

each student therefore proceeds at his own learning pace.This adaptability is an important and helpful feature of theteaching machine. Another advantage is that the teachermust think clearly and logically about his subject beforehe sets it down in a programme.There is no suggestion that programmed learning should

replace the lecturer or any of the traditional instruments ofteaching. But in certain areas of medical education thismay prove the best way to ensure that the student under-stands as well as remembers what he is taught. Thefurther results of the experiment begun by Owen and hiscolleagues will be awaited with interest by all medicalteachers.

ADDICTION TO PETROL VAPOUR

ATTENTION has again been drawn to an unfamiliardanger of petrol-addiction to its vapour. Adults,adolescents, and children have all been affected. Gold 1

describes a boy of 14 who had taken to sniffing his secretstore of petrol whenever he felt " down " or unhappy.This went on for five months until he collapsed un-conscious after a session with the vapour: he was found,and his petrol store was thrown away. Despite protesta-tions of abstinence he was discovered six weeks later

1. Gold, N. Med. J. Aust. 1963, ii, 582.

inhaling vapour from a motor-cycle fuel tank. Hisimmediate background was one of insecurity, and therewas a young stepmother. Apparently successful weaningfrom his addiction was followed in sixteen months byrelapse when he was exposed to social stresses.The reports of petrol-vapour sniffing in children

suggest that the prognosis is poor even with vigoroustreatment. The toxic vapour can cause death; and thepostmortem findings are likely to be visceral hxmorrhagesand degenerative changes in the liver and kidneys.

PREINVASIVE CANCER OF THE CERVIX

THERE are no symptoms or signs characteristic of

preinvasive cancer of the cervix, and the first suspicionof serious disease generally arises when a routine smearis positive. The nature of the lesion is established bycareful histological examination of an ample cone biopsyspecimen containing the whole squamocolumnar junctionand a wide circle of epithelium surrounding the externalos, together with most of the mucosa of the cervicalcanal. 1 2 Way has emphasised the need for a largebiopsy specimen and for care in handling and fixing thespecimen, and he has detailed his own technique. Theseare first and important steps in management. Even withgood sections, the subtle distinctions between dysplasiaand preinvasive and microinvasive cancer are hard

enough to interpret. When the material is inadequate orthe structure of the tissues distorted by rough handlingor poor fixation, it may become impossible for the

pathologist to give a useful opinion.If examination shows preinvasive cancer, there are

strong arguments in favour of hysterectomy for olderwomen and those with families.3 4 Regression may takeplace spontaneously or after cone biopsy, but there is nomeans of determining which lesions will regress andwhich will become invasive. Some patients have beenfollowed by repeated biopsy through the phases of

dysplasia, preinvasion, and invasion. Nor is it possibleto tell how long cancer-in-situ has been present, andalthough progression to invasive cancer may take anaverage of five years it could be a matter of monthsin a longstanding lesion.2 8 When cone biopsy or otherconservative treatment is followed by hysterectomy,residual carcinoma is found in the uterus in 8-50% ofcases.9-13 This is the immediate risk. Less is known of theoutcome for patients who do not have a hysterectomy; insome the smear becomes negative after local excision, buta long follow-up would be of particular interest.Way advises a modified radical hysterectomy, removing

uterus and cervix with the inner third of the parametriumand upper third of the vagina; it is unnecessary to removethe ovaries unless they are diseased. 1 2 The best timefor operation is four to six weeks after cone biopsy whenoedema and inflammatory reactions have settled.

Conservative treatment-either cone biopsy or amputa-1. Way, S. The Diagnosis of Early Carcinoma of the Cervix. London, 1963.2. Fluhmann, C. F. The Cervix Uteri and its Diseases. Philadelphia, 1961.3. TeLinde, R. W., Galvin, G. A., Jones, H. W. Amer. J. Obstet. Gynec.

1957, 74, 792.4. Morton, D. C. Postgrad. Med. 1961, 30, 453.5. Galvin, G. A. Radiology, 1950, 54, 815.6. Dunn, J. E. Cancer, 1953, 6, 873.7. Dunn, J. E. Amer. J. publ. Hlth, 1958, 48, 861.8. Jones, H. W., Galvin, G. A., TeLinde, R. W. Proceedings of United

States Third National Cancer Conference; p. 678. Philadelphia, 1957.9. Gough, H. M. Canad. med. Ass. J. 1962, 86, 974.

10. Hester, L. L., Read, R. A. Amer. J. Obstet. Gynec. 1960, 80, 715.11. Schulman, H., Cavanagh, D. Cancer, 1961, 14, 795.12. Younge, P. A., Hertig, A. T., Armstrong, D. Amer. J. Obstet. Gynec.

1949, 58, 867.13. Younge, P. A. Proceedings of United States Third National Cancer

Conference; p. 682. Philadelphia, 1957.