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Attractive though the concept of the communityhospital may seem from some points of view, there arepossible drawbacks, and very careful study is neededbefore deciding what role, if any, the communityhospital should play. From the data available so farwe cannot determine the efficacy of care given todifferent groups of patients. Some of these data canbe interpreted critically. For example, 8 of the 38patients for whom immediate admission to hospitalwas considered necessary were subsequently trans-ferred from the community hospital to the districtgeneral hospital. It could be argued that they shouldnot have been admitted to the ward in the first place.Other data can be interpreted favourably, but it is

impossible to base any conclusions on evidenceavailable from such a simple descriptive exercise.Because of this a full-scale experiment is beginning.A new community hospital is now being built in the

Oxford region to serve the population of a small

country town and surrounding rural area, some fifteenmiles from the nearest district general hospital. Thefirst phase of building will provide a health centre,geriatric day hospital, 17 maternity beds, 17 generalbeds: the second phase will provide a further 34-bedgeneral ward unit. As a result the existing inpatientunits in the town will be closed, and it is planned thatlong-stay geriatric patients from the communityserved will be cared for in the new hospital. Theinternal environment of the hospital will have certain" domestic " characteristics and the developmentwhen complete will provide what are considered to bethe appropriate services at the right level in a suitableenvironment near the centre of the community served.This whole development will be regarded as an experi-ment and made the subject of critical evaluation. Theresults will influence plans for modifying the role ofexisting small hospitals throughout the region and willdetermine whether or not similar hospitals should beprovided on a more extensive scale.We thank Dr. P. M. R. Hemphill, Dr. T. 1. Stewart, and

Dr. E. Rosemary Rue; hospital board and management com-mittee staff; Mrs. N. C. Boyle and the nursing staff; Mrs. M.Tuke-Hastings, Mrs. J. G. Banks, and Mrs. J. E. Seegers;Prof. R. N. Curnow, Miss S. B. J. Macfarlane, and Mr. M. R.Bathe, of Reading University, for the work study; Dr. J. A.Baldwin and staff of the O.R.L.S. for data on hospital discharges;Sir Richard Doll for his advice and encouragement; and MissP. Carr and Miss C. Lewis for help in preparing this report.

Requests for reprints should be addressed to A. E. B., 9 KebleRoad, Oxford OX1 3QG.

REFERENCES

1. Ministry of Health Hospital Plan for England and Wales. Cmnd1604 H.M. Stationery Office, 1962.

2. Central Health Services Council. The Functions of the DistrictGeneral Hospital. H.M. Stationery Office, 1969.

3. The Work of a Cottage Hospital in a Rural Community. OxfordRegional Hospital Board, 1965.

4. General Practitioner and the Hospital Service in the 1970s. OxfordRegional Hospital Board, 1969.

5. Forsyth, G., Logan, R. F. L. The Demand for Medical Care.London, 1960.

6. Loudon, I. S. L. The Demand for Hospital Care. United OxfordHospitals, Radcliffe Infirmary, Oxford.

7. Gruer, R. Lancet, 1971, i, 390.8. Royal College of General Practitioners. Reports from General

Practice VIII: General Practice in South-West England. London,1968.

9. Acheson, E. D., Barr, A. Br. J. prev. soc. Med. 1965, 19, 164.10. Isaacs, B., Gunn, J., McKeckan, A., McMillan, I., Neville, Y.

Lancet, 1971, i, 1115.

Letters to the Editor

ELECTROCARDIOGRAPHY: STANDARDS,TECHNIQUES, AND TRAINING

DENNIS M. KRIKLER.

Cardiac Department,Prince of Wales’s Hospital,

London N15 4AW.

SIR,-While in the United States there are precisestandards for E.c.G. machines,l the Department of Healthand Social Security has yet to issue recommendationsleading to a British Standards Institute specification. Inthe meantime, machines may be sold without disclosure oftheir limitations; indeed, the quality of some well-knownbrands is goor.2 They may not completely block out direct-current skin potentials which compete with the signalgenerated by the heart, and their sensitivity to both highand low frequency signals is often inadequate. Fortunately,those who wish to check their own instrument can do so

quite simply and without special equipment.3 While priceis important, it seems a shame if cheapness involvessacrifice in quality-in the United States some manufac-turers have failed to come up to American Heart Associationstandards and thus have an unfair competitive advantage.’ 4There does not appear to be a battery-operated unit thatapproaches the American standards.1

It is, however, in the training of those who interprettracings that the principal problems arise. Cardiac infarc-tion, actual or suspected, is so important and frequent acause for referral to hospital that it is essential that thehouse-physician should be able to produce a record thatwill enable the diagnosis to be made or broken (where thisis medically reasonable) on high-quality tracings.5 While itis obviously impossible to teach the analysis of tracings inany depth in the undergraduate curriculum, it is a vitalconsideration during post-registration training. Too often,patients investigated because of poorly reported tracingsturn out to have minor changes that are well within thelimits of normal; and sometimes the junior doctor facedwith a highly unusual tracing is only too easily tempted tomake a bizarre diagnosis. This is also of great importancewith increasing access to E.C.G departments by generalpractitioners 7 (though many now have their own machines).Here it is even more important that trained staff read thetracings-at least until such time as mass screening bycomputer can be introduced. This at least would enableabnormal or uncertain tracings to be picked out and ana-lysed by experts.

Electrocardiography is one field where modern audio-visual teaching methods are likely to be invaluable, andwhere existing material could usefully be supplemented bysuitably designed films and slide-tape sets for demonstra-tion to audiences and for individual study.

MORBIDITY AND MORTALITY OF ABORTIONS

SiR,ņYou have drawn attention 9 to the increased riskof abortion with sterilisation (1-08 per 1000) comparedwith abortion alone (0-13 per 1000). 12 of the 17 deathswere associated with abortion and sterilisation in 11,126

1. Committee on Electrocardiography, American Heart Association.Circulation, 1967, 35, 583.

2. Gold, R. G. Wld med. Electron. 1967, 5, 292.3. Piller, L. W. S. Afr. med. J. 1966, 40, 613.4. Pipberger, H. V. Circulation, 1970, 42, 771.5. Bradlow, B. A. How to Produce a Readable Electrocardiogram.

Springfield, 1964.6. Krikler, D. M. Br. J. Hosp. Med. 1971, 5, 164.7. Verel, D. J. R. Coll. Physns, Lond. 1971, 5, 275.8. Friedberg, C. K. Prog. cardiovasc. Dis. 1970, 13, 86.9. Lancet, 1971, i, 979.