Conscientious objection is a problem involving both personalities and society. It has important military, political, ethical, religious and sometimes psychiatric aspects. It is only where conscientious objection arises in a person who shows signs of psychiatric disorder that the psychiatrist has to take an active professional interest. He has sometimes to treat patients struggling with the problem of conscientious objection and sometimes has to report on them to the Recruiting Medical Boards. Thus this aspect of conscientious objection becomes a part of war psychiatry. My own interest in the problem was aroused by seeing a number of psychiatric patients who were objectors.

In the present paper I do not intend to deal with those graver affections, such as apoplexy or paralysis, which frequently occur in the aged, and which depend on gross lesions of tissue. Nor shall I mention the severe and intractable neuralgias of advanced life. I desire to direct attention to a class of neuroses, which more or less inevitably attend the decline of life, and which, though they do not involve any serious catastrophe, are the cause of so much suffering that it is surprising that they should have received little or no systematic notice from medical writers. The neglect of these complaints is not merely a negative evil; for, owing to the fact that their neurotic nature is ignored, certain superficial symptoms which they present are treated as if they depended on functional disturbance of the liver, or ordinary stomach catarrh, &c., and very often with depressing remedies, which greatly aggravate the existing evil.

In psychiatry, generalization is a process which requires careful handling. It must be firmly rooted in everyday experience of the practical empiricism which gets results, and must be free, as far as possible, from the numerous fallacies which have brought “armchair” philosophizing into disrepute. These are formidable requirements, but fortunately one way of meeting them lies ready to hand. There are doubtless many others apparent to more fertile minds, but the one with which this paper deals rests on the fact that a patient who has been successfully treated by a psychiatrist behaves, when well again, in a different manner from that which he displayed when ill. He is cheerful, not depressed, relaxed, instead of being tense; realistic and socially enterprising as opposed to being autistic. If the term “Behaviour” is used in a sufficiently wide sense, it can cover the great majority of psychiatric phenomena without losing its cardinal virtue for the present purpose, namely that behaviour can be observed and its manifestations measured with considerable accuracy. The products of observation can be handled statistically, thereby avoiding armchair theorizing. Admittedly the interpretation of statistically derived findings presents some difficulty, but this is not insuperable. It is usually easier than the process of generalizing from observed data without the benefit of statistical pre-digestion.

The after-care of the male insane, to which I venture to draw your attention, with a view to discussion, is so closely allied to the objects of this Association that I trust its consideration may be not only of interest, but even of some practical usefulness. Although at present lying beyond the limits of our sphere of action, the time may arrive when our resources shall have so far developed that the annexation of this adjacent province may be both practicable and desirable.

The opportunity I have of speaking to you is for me both a pleasure and a privilege, but it is also, I fully appreciate, a responsibility.

The field of psychiatry to-day is not unfruitful and not a few discoveries of lasting worth appear to have been made, while certainly claims to progress of more doubtful value, both as regards letiology and even more with regard to treatment, are so numerous as to be rather bewildering, particularly when they become the subject of articles in the popular press, whereby relatives are enabled to make a diagnosis and decide on a line of treatment without any reference to the medical man.

In the past head injuries have been of comparatively little concern to the psychiatrist. As judged from statistics of admission to mental hospitals they are a small problem. Mapother (1937), for example, who took a very broad view of the causal connection found in L.C.C. mental hospitials—3 per thousand in observation wards, 4 per thousand in psychiatric O.P. depts. in general hospitals, 7 per thousand of the admissions attributable to head injuries. The increasing interest that psychiatrists take in head injuries at present is mainly due to the increasing amount of extramural work that they are being called on to do. In general hospital and outpatient practice they are bound to encounter a considerable number of problems connected with head injuries, both in the acute and in the later stages. The psychiatrists and neuro-psychiatrists in the Services have probably had this experience first, but when adequate provision of psychiatric service becomes available in the general hospitals, many cases will come into the orbit of psychiatrists which hitherto have been “disposed of” without much regard for their mental aspect.

The intelligence, as measured by standard tests, ceases growing after about 14 or 16 years of age, and slowly decreases from about 25 or 30 years of age (Wechsler, 1945). The sex glands are developing as the intelligence ceases to develop.

In view of these observations, consideration was given to the possibility that the defective developed mentally to a degree below the normal because too great a quantity of the appropriate sex hormones was circulating in the blood stream. In consequence, the opposite hormone was administered, stilboestral being given to males and pernandren to females.

This case has shown so great an improvement by symptomatic treatment with parasympathetic stimulants and a sympathetic depressant that it seems worthy of record for its own value, apart from the interesting investigations to which it leads.

Since the discovery that Bacillus coli vaccine (1) or albumose (2) were as effective as typhoid vaccine (3) in the treatment of typhoid fever, the use of non-specific protein therapy has been popular for almost any disease for which there is no other satisfactory form of treatment. T.A.B. vaccine, a mixture of typhoid and paratyphoid A and B organisms, has been found more regular and reliable in its results than typhoid vaccine (4); but milk, antitoxic sera, peptone and a variety of other substances have been used, and even malaria is considered a form of this treatment, segmentation of the parasites producing the foreign protein (5). It has been observed that Gram-negative organisms, such as the gonococcus and typhoid bacillus, produce more marked reactions when given intravenously than the Gram-positive organisms, such as staphylococci, streptococci and pneumococci (5).

When we find, as recorded in the book of Samuel, that the great Psalmist resorted to imposture and “feigned himself mad and scrabbled on the doors of the gate, and let his spittle fall down upon his beard;” we cannot be surprised if minds less gifted should, for whatever purpose, assume the character of a madman. The beautiful conceptions of Shakespeare unfold to us in its highest fulness the rôle to be sustained by the player who is “but mad in craft.” We are told how Hamlet:—

Repulsed,
Fell into a sadness; then into a fast;
Thence to a watch; thence into a weakness;
Thence to a lightness, and by this declension,
Into the madness wherein now he raves,
And all we mourn for,

and how Edgar, amid all his witless jabbering, himself exclaims aside :—

We have before us several papers and documents referring to this well-known hospital for the insane. Those who have paid the attention they deserve to the annual reports of the Commissioners in Lunacy will remember that, year by year, the site, the building, the internal arrangements, and the management of this institution, have been therein the subjects of censure and of earnest remonstrance, which the governors of the institution appear to have borne with remarkable equanimity, or perhaps more truly, with stolid apathy. In the earlier reports, the Commissioners put their recommendations in the mildest possible form; for instance, in June 1852, they suggest that “perhaps the governors may be disposed to consider favorably the hiring some land, &c.,” but during the past year, in which they visited the hospital twice, the Commissioners speak much more decidedly, “they regret very much to find that their suggestions have not been carried out, it is painful to them to revert so often to the various defects of the institution;” “the temperature of the galleries was much below what is usual in establishments of this nature; in the male wards being as low as 33° on February 29th, 1855; the extreme coldness of the hospital, together with the entire absence of furniture, presented a very bare and cheerless appearance, the means of occupation and amusement appear to be very scanty, &c.” We quote at length the report of the special inspection made by the noble Chairman of the Board, and two of the Visiting Commissioners.

Most of us are in the active discharge of the duties of medical attendance on the insane, many of us are at the head of large public institutions. We are by the public expected both to be learned, ready and exact. Serious calls are daily made on our knowledge of medicine and surgery, but by many of us I am certain these are much more readily responded to than the calls on our powers of administration and on our judicial functions as guardians and care-takers, as well as the physician and friend of our patient. Now to my mind no one portion of duty is more unpleasant than having to listen to complaints of illtreatment, or even negligence and carelessness made by patients, to investigate them, to weigh, balance and decide on the best course of action.

In the case of a person who is charged with an indictable offence, and who is alleged to be insane, the first question that presents itself for consideration is whether such accused person is, or is not, in a fit mental condition to be called upon to plead to the indictment, and to take his trial; for, according to the common law of England, as stated by Blackstone, in his Commentaries (Book 4, Chap. II): “If a man in his sound memory commits a capital offence, and before arraignment for it, he becomes mad, he ought not to be arraigned for it; because he is not able to plead to it with that advice and caution that he ought.” and this general principle of the common law was set out more fully in a statute passed in the year 1800 (39 and 40 Geo. III., cap. 94), by which it was enacted that “If any person indicted for any offence shall be insane, and shall, upon arraignment, be found so to be by a jury lawfully impanelled for that purpose, so that such person cannot be tried upon such indictment,” … “it shall be lawful for the Court before whom any such person shall be brought to be arraigned, or tried as aforesaid, to direct such finding to be recorded, and thereupon to order such person to be kept in strict custody until His Majesty's pleasure shall be known.”