220

growing on media containing 100 g. per ml. but thebulk of organisms were still streptomycin-sensitive.Throughout the study it was noted that the drug-resistant strains grew more slowly and developedsmaller colonies than the strains on the plain medium,which might suggest that even when strains are

becoming resistant to streptomycin there is still con-siderable interference with their vitality. Later, how-ever, as strains became more resistant they developedalmost as quickly and profusely on the streptomycinmedium as on the plain medium. This study there-fore confirms the view that development of strepto-mycin-resistant tubercle bacilli is associated with thenatural selection during treatment of the few resistantvariants initially present. It also shows that whereasthe usual method of testing for streptomycin-resistanceindicates a sudden change from sensitivity to resist-ance, in actual fact the change is very gradual; soclinical response to therapy may still be expected-as has indeed been noted-after the infecting strainhas apparently become resistant.

- The position seems to be similar in the penicillintherapy of staphylococcal infections, where the fewnaturally resistant staphylococci (resistant because

they produce penicillinase) gradually replace the bulkof sensitive strains, as is suggested by BARBEL, aFurther, her finding that an increase in the size ofthe inoculum may raise the in-vitro resistance of

staphylococci 800-fold is possibly explicable on thesame basis, and this is an important technical pointto laboratory workers engaged in testing the sensitivityof bacteria to penicillin or streptomycin.How the dangers of acquired drug-resistance are

to be overcome is still conjectural. Massive dosageat onset iri acute infections, intermittent therapy’for chronic infections, and combined therapy with twodrugs have all been suggested. Lately VOUREKA 4has described an apparently new phenomenon—the reversal of resistance to sensitivity by

" sensitisa-tion " with other bacterial cultures or their filtrates.She offers no explanation of this occurrence-whetherfor example the sensitising agent adsorbs the resistantstrains, or whether sensitised staphylococci lose theircapacity to produce penicillinase-but her work

certainly opens up a new field for the investigationof this troublesome property of bacteria.

3. Barber, M. J. Path. Bact. 1947, 59, 373.4. Voureka, A. Lancet, Jan. 10, p. 62.

Annotations

APPEAL TO THE COURTS

A SPECIAL’ correspondent’s atticle in last Saturday’sTimes must give further pause to those of us who haveargued that doctors in the National Health Servicewould have more security if complaints against themwere heard in the law-courts.

After pointing out that " the doctor in any form ofpublic service deserves special protection against hastycriticism or local prejudice," the correspondent describesthe protection now given in the National Health Insurancescheme. Here any serious case is referred by the localinsurance committee to the Ministry of Health, wherean inquiry committee, consisting of two doctors and apractising lawyer appointed by the Minister, reportson the facts and inferences of facts it believes to beestablished. The report then goes to an advisorycommittee consisting of three doctors.from the Minister’sstaff and three retired or practising insurance practitionersselected from a panel, and the Minister makes his decisionafter hearing its recommendations and after invitingthe doctor to submit evidence as to his character and

professional standing. Between 1924 and 1947 successiveMinisters have had to take decisions in 46 cases : 18doctors were formally excluded from the service and 12were allowed to resign ; and of those who later -appliedfor reinstatement only 3 have been refused.Though most of the N.H.I. disciplinary machinery

is retained in the National Health Service, the Ministerhas given up his right to terminate a doctor’s contract,and this power is now vested in a tribunal consisting ofa lawyer of at least ten years’ standing (nominated bythe Lord Chancellor), a layman, and a doctor chosenfrom a panel.

" Before this tribunal," writes the Times correspondent," the doctor will enjoy an unusual privilege. If the tribunaldecides in his favour it cannot be overruled. The initiatorof the complaint has no right of appeal. But if the decision

goes against the doctor he, and he alone, has the right toappeal to the Minister, and the Minister may then over-rule the tribunal.... Thus the only power which theMinister retains is a power to,protect the doctor againstan adverse decision, a power not of dismissal but of retentionin the service. When such an appeal is made to theMinister Mr. Bevan has indicated that it will probably

be dealt with in accordance with current N.H.I. procedure:the doctor would have the right to an oral hearing, inpublic if he wished ; and the report of the appeal proceed-ings would be referred to the Minister’s medical advisorycommittee for its recommendations before the Ministerdecided whether to risk retaining in the service a doctorwhom the tribunal wanted to discharge."

The law-courts are open to the doctor, as to any othercitizen in comparable circumstances, if he claims thatat any stage the various bodies concerned have failed tocomply with the conditions that must precede termi-nation of his contract. In proposing that he should be.able to appeal to the courts against the decision of thetribunal or the Minister, representatives of the professionare asking for something more than this " elementaryright of appeal to the courts," which is in fact preservedunder the Act. They are asking that the court shouldbe able to override a lawful decision of the tribunal orthe Minister ; and if it were granted to the doctor thisright to appeal against a decision (because it is undulysevere or inexpedient) could not possibly be denied tothe complainant. In many cases the doctor, whethersuccessful or unsuccessful in his case, would find privacyan advantage ; but with an appeal to the courts anycomplainant would have it in his power to expose himto public proceedings. Important as this might prove inpractice, even more weight, however, must be attachedto the Minister’s legal arguments summarised in theTi7nes as follows : °

" In all such cases the courts would be in the highlyembarrassing position, not of applying the law, but ofparticipating in managing the service ; of deciding, not

, whether the tribunal’s decision was lawful but whetherit was wise. If the principle were conceded it wouldimply that anyone aggrieved by the lawful terminationof his contract of service, whether a professor of medicine,a newspaper editor, a nurse, a miner, a teacher, or theassistant of a general practitioner, would be able to ask a-

court to order his reinstatement on grounds not of rightbut of expediency. The courts would be obliged to inter-fere with the general responsibility of managers for theefficient conduct of services and enterprises of everydescription. "

*

The Solicitors Jourital of Jan. 31 suggests that thisquestion of appeal to the courts might be referred to thelegal committee which is to consider whether partnershipagreements will remain valid after the appointed day.