Blakeman is a man of complete honour and integrity … The war came, and he saw service. His was not dishonourable service. He was with the Eighth Army, in one of the two brigades which Field Marshal Montgomery asked to be sent out to reinforce his troops at El Alamein. He was with the Eighth Army right through from El Alamein to the Italian campaign and the termination of his service came at Padua only after a period which he spent in hospital. It is true to say that few medical experts would hazard a precise guess as to the absolute predisposing causa sine qua non of schizophrenia. Nobody knows.Footnote 1
So argued Leslie Hale, the Conservative MP for Oldham West, in Parliament in December 1962 in defence of his constituent, Mr Joseph Blakeman, who had been denied a disability pension by the government. Hale was not the first MP to remonstrate against the minister of pensions for the unfair hardship of a deserving veteran, nor was he the first to inquire after the fate of veterans with schizophrenia. Already in 1947 the minister of pensions had been questioned by MPs on how many veterans discharged from service with schizophrenia had been refused pensions. Edward Evans, a Labour MP dedicated to improving legislation on disabilities, explained in Parliament that the ministry’s attitude towards ‘this very distressing malady’ was ‘causing a great deal of disquiet among the friends of these men’.Footnote 2 The stigma around schizophrenia at the time stemmed both from the affective intensity of the behaviour – hallucinations, delusions, thought disorder – and the eugenic assumption that the illness was hereditary and therefore a mark on the whole family. As the medical doctor and Labour MP Samuel Segal replied to Evans’s request for a more sympathetic attitude towards these veterans, ‘in many cases the incidence of this disease is attributable to hereditary factors and it cannot always be attributed to war service’.Footnote 3 The minister assured the House that ‘whatever sympathy and understanding are required in this very distressing class of case, we will do our best to meet the need’.Footnote 4
In the two and a half decades following the end of the Second World War this contest between the political desire for a sympathetic compensation of veterans with schizophrenia, the medical uncertainty over causation, and legal requirements of fair procedure played out across the war disability pensions system. The promise to provide sympathetic and fair compensation for these invalided veterans marks an important episode both in the history of the incipient welfare state and in the normalization of schizophrenia in public life.Footnote 5 However, as these opening scenes from Parliament suggest, there remained discontent over the handling of these cases. This paper follows the interaction of medical expertise, legal procedure and governmental administration in order to show how the political promise of sympathy and understanding was realized in practice.
There is a well-established literature on post-combat psychological disability which clusters around the First World War and the Vietnam War, detailing the diagnostic entities of shell shock and post-traumatic stress disorder respectively.Footnote 6 In the British context, a team of researchers led by psychiatrist Edgar Jones have used the Ministry of Pensions archives to argue that changing fortunes in the war pensions reflect broader shifts in popular understandings of post-combat syndromes. The arguments developed below build on this work while going into more detail, focusing on a single disease category, and exploring how the pension appeal tribunals (PATs) and their legal regulation by the high courts tell a more complex story. Rather than use these sources solely as a bellwether for macro-scale changes in popular understanding of psychosis, this paper examines at the micro-historical level how psychiatric knowledge is modified and made use of in legally regulated settings. The enduring uncertainty over the causes of schizophrenia, unlike the well-known post-combat syndromes, has – as Peter Barham has argued for veterans of the First World War – negatively shaped the fates of veterans with this diagnosis.Footnote 7 For the most part, the medical consensus that schizophrenia is a primarily hereditary disease which occurs in civilian life and has no relation to war stress ensured that appeals for disability pensions were mostly denied. However, in post-war Britain several legal interventions transformed this situation and increasing numbers of pensions were awarded. This paper teases out how these legal interventions pushed the system of PATs and the War Pensions Department (WPD) initially into producing sympathetic outcomes for schizophrenia cases, and how the system continually struggled to balance decisions between medical and legal notions of evidence and causation.
This story can only be told because of the extant files from the PATs and the Ministry of Pensions, and from published legal case summaries. The UK National Archives holds around seven hundred files from the PATs in England and Wales dating from the 1957–93 period – earlier files were destroyed – as well as files from the department responsible for war disability pensions, of which only a handful relate to schizophrenia. In addition, details of important cases are found in the Reports of Selected War Pensions Cases which were put together primarily for use by civil servants working within the WPD.Footnote 8 The cases of schizophrenia are displayed in the table in the appendix. The ‘Fit for War, Fit for a Pension’ principle introduced with a new royal warrant in 1943 meant that the tribunals were compelled to approach schizophrenia as a disability which had developed in a fit and healthy normal person, which went against the medical consensus that schizophrenia was the genetically determined disintegration of an individual’s personality. In a legally and politically sympathetic setting, the narrative of disablement could displace the psychiatric natural history. Not only was the onus of evidence in the veteran’s favour, but there was a desire to fit their life story into the model of a soldier who had served his country and suffered for it in the process. The medical, legal and moral reasoning which takes place in the tribunals circles around the question whether the veteran’s biography better fits the military-disability story or the civilian-disease story. While the archival sources are incomplete, the majority of the early cases in which the high courts intervened all fit within a particular narrative of extraordinary combat-related stress followed by a mental breakdown. For those who had what were deemed less valuable or less stressful military careers, a pension is typically denied. In the few extant case materials from the 1960s onwards, the one exception takes place on a legal technicality against the evidence, most likely as the given individual had legal representation and had held a senior military rank.
At the heart of this story is the boundary object which bridged the medical and legal systems: specific severe stress.Footnote 9 While stress was ostensibly a common object between the medical expert and the non-medical mind, there was in fact no agreement or alignment over what relevant stress was. For the veterans, their representatives and the judges of Britain’s higher courts, causally relevant stress was given a common-sense interpretation, embedded in sympathetic narratives of honour and sacrifice, while for the medical expert, stress was a background factor in the story of a civilian disease which happened to emerge during wartime. Stress-triggered schizophrenia was a hybrid creation of the whole system, which was brought into existence by medico-legal boundary crossing. Making invalidity fair meant dethroning the genetic determinism of the psychiatric consensus and including stress-triggered schizophrenia in the imagined collective of disabilities deserving war pensions. This was a small but significant early phase of the broader historical process in which psychiatry, through its entry into the bureaucratic machinery of the welfare state and judicial regulation, was made more accountable and its ignorance made more visible to the public.Footnote 10
The war disability pensions system in Britain
War disability pensions were introduced after the First World War and were one of the earliest forms of social security in the UK. They were compensatory in nature, not dependent upon contributions, reflected military rank, and were more generous than civil benefits. In the interwar period war pensions were the single largest output for welfare spending by the UK government. When the Ministry of Pensions took over benefit powers from the Admiralty in 1916, it shifted the criteria for eligibility for state support. Prior to this an award was based on an assessment of a veteran’s capacity to earn a living wage; from now on it was to be based on a standardized schedule, with financial help scaled to the level of disability due to or aggravated by military service.Footnote 11 However, those using this new standardized system struggled to accommodate psychological disability, such as shell shock. By 1918 a solution was settled upon to differentiate between recoverable and non-recoverable shell shock, and whether the shell shock was attributable to or aggravated by service.Footnote 12
A pensions appeal tribunal for servicemen and their widows had already been established in 1917 within the Ministry of Pensions, but shortly after the end of the war independent PATs were established to consider appeals against the ministry. The tribunal consisted of a legally trained chairman, a medical member and a lay member, and the hearing was typically attended by the appellant and their representative.Footnote 13 These PATs were, and remain, entirely independent of the government departments, and were under the authority of the Lord Chancellor in England and Wales, the Lord President of the Court of Session in Scotland and the Lord Chief Justice in Northern Ireland.
The task of appealing a pension entitlement began with receiving a rejection to entitlement, after which a veteran might get in touch with one of the several voluntary ex-service associations providing legal advice (the Officers’ Association for officers and their widows; the Royal British Legion for officers and other ranks; the Royal Air Force’s Association for officers and their widows), a trade union or a member of the local war pensions committee. Having received legal advice, the veteran submitted an official form to the Ministry of Pensions, who then began gathering evidence for the ‘statement of case’ – employment history, medical records, official medical opinion, reasons given by appellant – which included the reasons for the initial rejection. Before the tribunal the statement was provided to the appellant, who had the chance to respond with any further information or reasons in support of their appeal. Finally, if the veteran did not give up at this point, they would attend a tribunal hearing, which was a fairly informal meeting of the legal chairman, the medical and lay members and the appellant and their representative, to debate the case.Footnote 14
There were two types of appeal – entitlement appeals and assessment appeals – and the WPD was only required by law to provide an official medical opinion in cases of the former. In entitlement appeals, a medical opinion was produced so that the PAT could properly evaluate all the medical facts. In assessment appeals, no opinion was included in straightforward cases, but only where extra explanation was required – for instance where a non-accepted disability caused symptoms similar to those of an accepted disability.Footnote 15 The department’s policy on assessment appeals regularly changed, with a shift towards providing opinions for all assessment appeals in the mid-1960s. By the late 1970s, they were considered unnecessary and expensive by the department, leading to tensions with representatives from the Royal British Legion.Footnote 16 While it is hard to give precise numbers, there was a relative rise in the proportion of invaliding due to psychiatric disorders and an absolute decline in the number of veterans given pensions for psychiatric disorders between the world wars.
Defending veterans from the tyranny of technocracy
The climate of sympathy towards disabled veterans during and directly after the war represented a challenge to the pessimistic and eugenic narratives of psychosis as a purely hereditary illness and allowed for more sympathetic causal narratives which emphasized exceptionally stressful experiences. The immediate post-war period in the UK, as in most other belligerent states, saw a dramatic rise in the prominence of social psychiatry and increased popular acceptance of psychological models of mental illness.Footnote 17 The origins of therapeutic communities in the UK were in military contexts, where medical education and group therapy were used with disabled veterans.Footnote 18 The Ministry of Pensions, however, remained heavily influenced by constitutional and hereditary approaches to mental disorder. In 1939 a medical committee of neurologists and psychiatrists under the remit of the Ministry of Pensions established a policy of favouring therapy rather than pensions for veterans diagnosed with neurosis, while emphasizing the constitutional and non-environmental origin of the psychoses, schizophrenia and manic-depressive psychosis.Footnote 19 Pressure for new legislation on war pensions and reform of the tribunals had been growing from politicians and doctors, as well as disagreements between the Ministry of Pensions and the trade unions after the former had rejected pensions for traumatized seamen after a torpedo attack in 1941.Footnote 20
The 1943 Pensions Appeal Tribunal Act (PATA) and royal warrant of the same year introduced a new clause removing the onus of evidence from veterans appealing their entitlement and enshrined the ‘Fit for War, Fit for a Pension’ principle.Footnote 21 It also included a clause which allowed either the appellant or the minister to appeal to the higher courts if they believed a case was in error on a point of law. It was not long before cases were brought to the High Court in England and the Court of Session in Scotland concerning the rejection of a pension for schizophrenia. In 1946 several such appeals made it to the higher courts.
In one of the first cases of schizophrenia that made it to the High Court, judge Alfred Thomas Denning ruled that the tribunal had not only been overly deferential to the medical consultant but also erred legally by misinterpreting his opinion. The doctor who gave the medical opinion in this case was the Scottish psychiatrist W. Ronald D. Fairbairn, who was a consultant to the Ministry of Pensions throughout the 1940s and 1950s. Fairbairn was unlike the majority of his senior English colleagues who contributed to the ministry’s strongly organic view of schizophrenia. He was a practising psychoanalyst and sympathetic to the view that schizophrenia was not a disease entity as such but a type of reaction of the entire personality to the events of life. In this view, which was common among Scottish psychiatric consultants in the post-war era, the life history of the schizophrenic individual was important for understanding the development of their personality.Footnote 22 The tribunal had rejected the pension appeal on grounds stemming from the ministry’s official opinion – that ‘schizophrenia is a common mental disorder of constitutional origin which characteristically manifests itself without regard to external circumstances and has nothing to do with service life and such incidents of that life as the appellant has experienced’. However, Denning pointed out that Fairbairn’s report on the appellant did not state that schizophrenia has ‘nothing to do with service life’, but actually claimed that it may be influenced by service ‘in those cases in which some specific severe stress precedes the onset of acute symptoms’. As Denning concluded,
In this case the man had all this long service, was in the Sicily landings, was in an accident in the Sicily landings, went into hospital and had malaria in hospital, and it seems to me that on all that evidence there is evidence of a specific severe stress preceding the onset of these acute symptoms. At all events there is no evidence which negatives any specific severe stress.Footnote 23
In the same year, the Court of Session in Scotland passed judgments on a set of sixteen cases, all of which involved debate on the meaning of ‘attributable’ and the role of medical evidence. The Lord Justice Clerks Mackay, Jamieson and Stevenson explained in this judgment that ‘the term “attributable” postulates a search for causation, but questions of causation must be approached, not in the metaphysical or scientific sense, but in the wider and more liberal sense as understood by the man in the street applying common-sense standards’.Footnote 24 Moreover, the judges sought to remind the tribunals that predisposition to a disease is not the same as having a disease, while medical evidence ‘which is no more than a general description of the nature of a disease is not sufficient to negative entitlement’.Footnote 25 They objected that
the Ministry’s views about certain common diseases have come to be expressed in technical formulas, not always identical, which suggest that, because the precise scientific cause of a disease is not yet known and because the disease occurs amongst civilian personnel, therefore its onset cannot be attributed to service conditions. If some of the opinions expressed by the Ministry were subjected to the cross-examination which they would receive in a court of law, we venture to doubt whether they would survive that test.Footnote 26
They took issue with the technical phrases used in the ministry medical opinions, such as that the disease ‘is of unknown origin’, or ‘insidious in onset’ or ‘of endogenous aetiology’ or ‘it occurs without reference to any known extrinsic factor’, arguing that ‘these statements only amount to the admission that ‘no one knows what causes the disease, from which we should have inferred that the Ministry could not possibly discharge the onus of proving beyond reasonable doubt that service conditions do not cause it’.Footnote 27 In concluding their attack, the judges reiterated,
The services must in our view take such a man as they find him … Unless the Minister can prove beyond reasonable doubt that the service conditions played no part at all in producing the disease, a pension must be awarded, predisposition or no predisposition, for predisposition to a disease is not a disease.Footnote 28
Similarly to the Scottish judges, Denning consolidated his reasoning with regard to diseases of unknown aetiology. In the following year, Denning ruled on the case of a veteran appealing for his throat cancer by comparing cases in which the aetiology of a disease was unknown, grouping his discussion of oesophageal cancer with cases of schizophrenia. The whole passage is remarkable for its transformation of the incommensurable medical opinions on schizophrenia into a merely factual problem of identifying severe stress:
in schizophrenia, although the precise cause is unknown, experience shows that in the great majority of cases it is essentially independent of external circumstances. That makes it highly probable that in the ordinary way schizophrenia is not attributable to or aggravated by war service, and claims have been rejected accordingly: see Briggs (5), and Burbidge (6); but the weight of this evidence may be counterbalanced if there is anything reasonably to suggest in the particular case that any incident of war service may have played a part, such as exceptional stress or strain immediately preceding the onset of symptoms. Medical men cannot exclude that as a precipitating cause, because statistics show that in a minority of cases schizophrenia has been preceded by severe stress. In such cases, therefore, claims have been allowed: see Forster (7).Footnote 29
The subtle but crucial point is that, in Denning’s reasoning, the challenge of the uncertainty when judging the evidence of an appeal for schizophrenia could be dealt with as a fact-finding problem using the specific criterion of severe stress preceding symptoms. He cites his own ruling in Forster as evidence that specific stress is a precipitating cause, ignoring the fact – intentionally or not – that in that very case he himself had intervened and utilized a professional conflict of opinion to push the case in the appellant’s favour.
In 1949 Denning gave the Hamlyn Lectures, ‘Freedom under the law’, in which he argued that the judiciary must play an integral part in the new ‘welfare state’ by ensuring that the power given to the administrators in the various government departments did not lead to the creep of totalitarianism. Administrative regulation was essential because ‘the Jack-in-office never realises that he is being a little tyrant’.Footnote 30 For Denning, the ability of the tribunals to appeal to a higher court which was independent of the government departments was essential to maintaining liberty and was a key difference between the British and the Soviet tribunal systems.Footnote 31 Denning ensured that the tribunals must decide unanimously rather than by a majority vote, and, in the case of disagreement, must make an appeal to a higher court. Moreover, he ruled that the tribunals only make decisions based on the independent medical evidence presented during the hearing, in order to prevent the ministry from being selective in its presentation of the medical opinion.
As the legal historian Patrick Polden has argued, ‘Denning’s achievement in pensions cases, therefore, was principally to impose on an informal, expert tribunal, the traditional model of due process developed by the courts of law, and to ensure by unprecedentedly close supervision that the claimants received the “justice” to which they were entitled.’Footnote 32 The interventions of Denning and the Scottish Lord Justice Clerks resulted in a steady stream of veterans, encouraged and supported by the Royal British Legion, who took their chances and appealed. As of 1947 the PATs had received 2,100 appeals against rejection for pensions due to psychosis and had allowed 450 of them.Footnote 33 By 1953 the ministry was, as a proportion of all veteran pensions, paying more for psychological and neurological problems than it had after the First World War, and the 1960s saw sixty-five to seventy appeals every year for pensions by veterans diagnosed with schizophrenia.Footnote 34
Contesting stress-triggered schizophrenia in the PATs
The ruling by Denning that cases with ‘specific severe stress’ could result in an award of ‘attributable to service’ created ongoing problems both for the WPD’s attempt to provide standardized decisions on pension applications and for the PATs tasked with evaluating an appeal. The schizophrenia cases which were either appealed to the higher courts or can be reconstructed from the archives of the Ministry of Pensions (see appendix) reveal that the identification of severe stress was case by case and defied any theory of pathogenic stress. If there is any broader pattern, it is that mostly extreme combat-related stress is considered relevant. Of all the cases listed in the appendix, most of the successful appeals involve combat action (3, 6, 17, 22), with only two exceptions (7, 20). This was central because the main argument of the ministry medical opinion was that schizophrenia was a disease of civilian life which did not increase in incidence during wartime; therefore service stress was considered unrelated. The psychiatric experts typically sought to show how the history of illness resembled that seen in civilian life.
As already noted in the discussion of Denning’s interventions in early schizophrenia cases, the medical opinion put forward by the WPD emphasized that schizophrenia was a constitutional disease which could not be caused by service stress. The Ministry of Pensions archive contains several copies of the appendix used by the WPD when deciding on pension claims. From the 1940s until the end of the 1960s, there was little change in the appendix other than updated textbook references. In a key passage of the appendix, the idea of pathogenic stress was discredited explicitly:
Even where early symptoms become noticeable in association with such an incident [of stress], it is often no more than one of the ordinary ups and downs of everyday life, such as leaving home to become independent for the first time, an emotional upset, a love affair, a bereavement, some physical illness or at childbirth. Such incidents, which are simply the price of living at all, cannot really be regarded as a cause of the appearance of the disease.Footnote 35
The civil servants in the WPD responsible for writing up the ‘statements of case’ were required to use a standardized method for writing up schizophrenia cases which put appellants into one of four categories. These categories fit the relevant sections of the medical opinion together with the legal standard of evidence to select the line of argument required to defend the case, either rejecting the claim outright, arguing that it was aggravated only, or arguing that it was attributable. For instance, where there was evidence of disease prior to service and no evidence of severe stress, then the decision writer should explain that the medical consensus was for non-attributable and non-aggravated. However, in a case with no signs of disease prior to service and evidence of service stress, and where the onus of evidence was on the WPD, there was reasonable doubt for an entitlement of attributability.Footnote 36
A close reading and reconstruction of three cases from the Ministry of Pensions archive gives a sense of how vital the legal standard of evidence was to a successful claim, how translating between medical and legal notions of causation relied on highly subjective evaluations of character, and how the WPD took two decades to incorporate stress-triggered schizophrenia into its standards for decision making. The last names have been changed to protect the anonymity of the individuals whose cases are discussed.
Ms Stella Booth: entitlement appeal rejected 11 September 1962
Stella Booth is the only female schizophrenia case in the archives. She was called up to the army in 1941 at the age of twenty-one, to serve in the kitchens and mess hall at a military barracks in Cardiff.Footnote 37 The work involved carrying food back and forth in the pouring rain and she later reported being hounded by the battery sergeant major, who continuously complained about the food she served in often abusive language. Booth also complained of rheumatism in her legs, but the doctors found no abnormality, suggesting that she ‘held her legs in a state of hysterical rigidity’.Footnote 38 After two years of working at the barracks, Booth was invalided as a result of her mental decline. The psychiatric specialist wrote in her medical report that she had an ‘inadequate personality’ and noted that she ‘appears morose – dejected and is not likely to perform any efficient service in the army’.Footnote 39
After being discharged, Booth was voluntarily admitted to the local mental hospital several times from 1951 to 1960, where she received various physical treatments for what was diagnosed as schizophrenia. She was first admitted after an attempted suicide, which seems to have been precipitated by her husband leaving her for another woman; his departure in 1946 resulted in her experiencing severe anxiety and auditory hallucinations associated with the shame of being left. After being discharged from hospital again in 1960, finding herself without a husband and living with her elderly and now blind mother, she decided to claim a war pension for what she called her ‘nervous condition affecting my legs’. This was rejected by the Ministry of Pensions on the basis that her real diagnosis was schizo-affective psychosis and that this was considered to be a hereditary and constitutional disease. She decided to appeal and the following year a tribunal met to discuss whether her service had in fact caused or aggravated her disability. Booth was too sick to attend her own tribunal. While the additional medical report acquired by the Royal British Legion made the case that the stress experienced by Booth was exceptional to her, and that that was what mattered, the ministry response was dismissive. The key argument was about the course of Booth’s illness after being invalided, which fluctuated in relation to domestic conflict. As the ministry medical opinion concluded, ‘The history of Mrs [Booth’s] case is, in fact, the same as we would expect to a similar case in civil life.’Footnote 40 Ultimately, because on the recorded evidence – Booth’s medical and service records – there was no mention of severe stress during service or of the schizophrenia starting immediately following discharge, the tribunal decided to reject the appeal.
Mr Charles Maurice Farmer: entitlement appeal of disability rejected 2 December 1968
Mr Charles Maurice Farmer’s appeal was first heard on 7 December 1967 within the Ministry of Social Security but was deferred so that the minister could consult with medical experts on the case. Farmer’s disabilities had been diagnosed in 1961 as ‘inadequate personality’ and ‘paranoid schizophrenia’, which he claimed were connected with his service in the armed forces between 1940 and 1946. His ‘statement of case’ was prepared by the WPD and sent for consideration by two consultant psychiatrists.Footnote 41 One of these was James Willis, a senior consultant psychiatrist based in London and author of a popular general introduction to psychiatry.Footnote 42 In his Lecture Notes on Psychiatry (1964) Willis set out a balanced view of schizophrenia, covering aetiological insights across heredity, personality, childhood, body build, metabolic studies, physical illness, life changes and psychological factors.Footnote 43 He suggested that a comprehensive ‘multiple aetiology’ would be most appropriate, whereby the illness follows a common biochemical final path, takes place in a genetically predisposed individual, and can be ‘triggered off’ by a variety of physical or psychological stresses.Footnote 44 Willis submitted a report suggesting that it was ‘beyond doubt that [Farmer] has suffered from paranoid schizophrenia’. He dismissed the diagnosis of ‘inadequate personality’ as highly subjective: ‘this is a term freely bestowed by psychiatrists on individuals for reasons which may have more to do with the psychiatrists’ own personal feelings and value judgements than on [sic] objective clinical enquiry.’Footnote 45 Willis proposed that Farmer’s chronic anxiety pre-dated the war, the stress of which probably induced his skin problems and psychotic breakdown – ‘I suggest that Mr. Farmer was a chronic anxious man who never made a satisfactory adjustment to life and who later broke down in psychotic fashion.’Footnote 46 He argued that it was customary to disregard ‘antecedent experience’ with a diagnosis of paranoid schizophrenia, but there was insufficient evidence to rule out ‘that his wartime experience did not contribute to the exacerbation of this and to his ultimate psychotic breakdown’.Footnote 47
The second psychiatrist, Maurice Partridge, was a senior consultant at St George’s Hospital and co-authored the textbook Psychological Medicine: A Short Introduction to Psychiatry, known ‘for its common sense and conservative approach’.Footnote 48 He agreed with Willis that Farmer had suffered from paranoid schizophrenia but repeated the accepted opinion that the psychosis was ‘constitutionally determined’. His report argued the delayed onset in 1963, seventeen years after Mr Farmer’s service at the time of the D-Day landing in 1944, suggested that the psychosis was unrelated. He acknowledged, however, that the patient’s behaviour had been ‘psychotic in some form’ before the ‘overt breakdown’ in 1963. Farmer had lost his job at the bank in 1951 after being told that he was ‘mentally unsuited to the work’ and had failed to hold down all of his subsequent jobs, one of which ended with him attacking a filing cabinet. Moreover, Partridge noted suspiciously that Farmer had spent a considerable amount of time ‘out of work and travelling around on a bicycle’, implying that such activities were indications more of vagrancy than of sickness. He commented on the patient’s neurodermatitis, which was probably related to ‘battle stress’. Finally, Partridge also dismissed the diagnosis of ‘inadequate personality’, both for its lack of reliability and for its inaccuracy in this case. Farmer had, after all, he argued, served continuously from June 1940 to June 1946 without incident and was in Partridge’s assessment at present holding himself together remarkably.Footnote 49
From the record of the second tribunal made by the ministry representative, Mr Oxley (2 December 1968), we learn that Mr Farmer described to those present how the problems began after his participation in the D-Day landings of 1944. As Oxley reported, the appellant said his service was quite satisfactory until he went overseas soon after D-Day. For the first few weeks the battalion was pinned down and there were no reinforcements coming through to replace casualties: as he put it, ‘they went through a hell of a time’.Footnote 50 Farmer noted that upon returning to civilian life he was pressured to leave his job at the bank because ‘he made too many mistakes’. After the war he considered himself ‘psychotic’, but managed to work with British Railways for almost five years, eventually leaving for want of prospects. Then he took short jobs with Thomas Cook and Son in London, but was ‘dismissed because his face did not fit’. He then worked with a chartered accountant for six months, but was dismissed ‘for trying to bash down the filing cabinets’. He got another company job for two years, but hadn’t worked since. At the time of the hearing he was spending his time ‘watching television, writing essays and going to art classes’.Footnote 51
Oxley’s report then records the psychiatric opinions of Willis and Partridge, summarizing their fairly similar conclusions. While they acknowledge that the appellant suffered from a ‘chronic anxiety state’ which ‘was affected by his wartime experiences’, they both discredited the idea that his psychosis was caused by service. Finally, the report includes the comments of the British Legion representative for Mr Farmer. He argued that ‘it was difficult to see the distinction between the psychoneurosis and the psychosis’.Footnote 52 Moreover, ‘it was a moot point whether there was any distinction. The psychosis had developed over a long period and it was reasonable to assume that it was present before it was recognised’. The crucial point of law was that this case was under Article 5 of the PATA (1943), which meant that Farmer – not the ministry – was required to show beyond reasonable doubt that service had aggravated his illness. Oxley argued that if Dr Willis could have ‘come down more strongly on the man’s side he would have done so’ and that Dr Partridge had ‘to a large extent supported the man’ and therefore his opinion that the psychosis was unaffected by service was likely impartial.Footnote 53 Oxley reported, ‘We have been very carefully through the evidence in this very difficult case and have come to the conclusion that it has not been shown that psychosis is attributable to or aggravated by service.’Footnote 54 The criticisms of both psychiatrists of the diagnosis of ‘inadequate personality’ led to its diagnosis as a ‘single entity’ being removed from the department’s medical guidelines. In a note from Oxley to the head of the WPD, Charles Byrne, he reported the chairmen’s unease at the opinions of Willis and Partridge on inadequate personality. Sir Stafford pointed out that the ministry had often argued that inadequate personality and psychoneurosis were inseparable and that it was ‘disturbing when one thought of the number of cases of inadequate personality which had been considered by himself’. As he concluded, ‘The doctor who signed the medical opinion has been made to eat his own words.’Footnote 55
Mr Herbert James Cartwright: appeal against entitlement accepted on 3 February 1970
In 1960 Mr Herbert James Cartwright began working as a peacetime major in Germany.Footnote 56 His job involved working long hours and weekends conducting administrative paperwork and the court records Mr Cartwright complaining that he was hounded by a senior officer who was always finding fault with his work. This led to sleepless nights and Cartwright seeking treatment for depression in 1964, and in 1968 he was invalided on account of schizophrenia. In the prepared medical opinion of the ministry of 27 June 1969 he was considered by a psychiatrist to have developed ‘peculiarities of thoughts and feelings’ and a ‘delusional condition’ which, given their late onset, were indicative of paranoid schizophrenia. The opinion of the WPD was that service may reasonably be considered to have aggravated the illness but ‘the condition on which the claim is based is not attributable to the appellant’s service’.Footnote 57 However, Cartwright won his appeal that his psychosis was attributable to service. On the one hand the case was under Article 4 of the royal warrant and it was on the WPD to prove beyond reasonable doubt that the illness was not attributable to service factors. On the other, because the ministry had already made the legal argument that his service was stressful enough to have aggravated his schizophrenia, they were unable to exclude beyond reasonable doubt the possibility that stress had triggered the disability. Thus the tribunal ruled that the stress had caused the illness, even though the notes from the WPD show that his service was not considered by the department representative as stressful as that of some other appellants.Footnote 58 He had been in service over twenty years and, having made the legal case that service played an aggravating role, given Denning’s ruling in 1948, the department were, in the words of the representative, ‘hoist by our own petard’ and pushed into accepting attribution.Footnote 59 Cartwright’s status as a major in the army, a position of considerable rank, no doubt played a part in the sympathetic treatment of his appeal. Unlike the other appellants, who were represented by members of the Royal British Legion, Cartwright was present and had a professional legal representative. However, the archives do not contain the actual report of the chairman, only that of the ministry representative, so it is impossible to say further how exactly the tribunal came to its decision.
The Cartwright case was one of several cases which led to the reform of the department’s use of categories for defending schizophrenia appeals. The CEO of the WPD, Charles Byrne, drafted a new guideline which required that each case be defended on the evidence of exceptional stress and its temporal relation to the onset of the illness. This reflected the department’s experience with defending claims and the PATs rulings that stress could be a proximate cause of psychosis and therefore veterans were entitled in certain cases to a pension based on the argument that schizophrenia was caused by service. As close scrutiny of the notes and guidelines of the WPD reveals, there was frustration not only with the difficulties associated with fitting individual cases into standard categories, but also with the absence of clarity in the medical guidelines regarding abnormal stress. For instance, in the copy of the 1968 appendix consulted by the author there is a handwritten note commenting on this section, ‘This deals only with “ordinary” (day to day) stress and adds nothing about abnormal stress.’Footnote 60 As Byrne explained in a circular note to the decision writers in the WPD, there was increased recognition by ‘medical and executive staff alike’ that the medical opinion on schizophrenia made producing a convincing legal argument difficult. In particular, as in the case of Herbert Cartwright, the medical opinion offered no advice on how to make clear that exceptional stress was not of aetiological significance but could only aggravate. With regard to the ongoing difficulties in defending the medical opinion on schizophrenia at tribunal, Byrne made the case that while the cause of the specific mental illness may be hereditary, service stress was in its ‘triggering’ role nonetheless a cause of ‘disablement’. In conclusion, it was argued that ‘in the light of our experience over the past few years we have now come to accept the Pensions Appeal Tribunal view that in certain circumstances schizophrenia can be attributable to service’.Footnote 61
It was only as the WPD found itself encountering legal difficulties in defending against schizophrenia appeals that the appendix and the official guidelines for formulating the medical opinion were changed such as to allow that, in some very exceptional cases, schizophrenia could be attributed to service stress. While the medical appendices reflected elements of the actual professional consensus, they were clearly written to maximize the arguments in favour of a hereditary aetiology and minimize any evidence supporting environmental factors. In the revised guidelines on writing up statements of case for schizophrenia, rather than emphasize that the probabilities are such that individuals who develop schizophrenia would always have done so, the emphasis is on the timing of onset:
The disease is essentially one which arises independently of external factors but where evidence of it appears for the first time in close time relationship to a period of exceptional mental strain, the nature of the latter may be such as to give rise to reasonable doubt that in its absence the disease might have remained latent … the mental illness cannot be attributable to or aggravated by service in the absence of evidence of exceptional service stress in close time relationship to the manifestation of mental disorder.Footnote 62
The difficulties in trying to standardize the cases into general categories based on a clinical picture led to a more pragmatic focus on asserting a purely genetic aetiology, except in cases where claims were being made explicitly with regard to specific stress, in which case a thorough investigation of the appellant’s medical record and medical advice was required before a decision was given. In this manner, the WPD accepted the possibility of stress-triggered schizophrenia into its arguments, but over two decades after Denning had ruled on the matter. By the time the new appendix and notes for guidance were implemented, the median age of war pensioners who had served in the Second World War and later was around sixty-one, and we can presume that the number of appeals for schizophrenia declined.
Conclusion
By bringing schizophrenia into the war disability pension system and subjecting the process of appeal to judicial procedure, the medical thinking on aetiology was challenged by a common-sense causal narrative, and a hybrid working solution was found in stress-triggered schizophrenia. There was no explicit theory of stress at work, but rather a complex mixture of causal narratives, evidential standards and social expectations of abnormal experience. While the war disability pensions system was set up to ensure a functional differentiation between administrative, medical and legal perspectives, in practice these functions overlapped and intersected: administrators often made medico-legal decisions about entitlement to and assessment of pensions, while lawyers and laymen made medical decisions about whether stress was abnormal or pathogenic in a given case. The analyses of schizophrenia cases in the war pensions system resonate with more recent assessments by historians that it was only during the Second World War and in its aftermath that the medical and mathematical notions of the normal increasingly converged, both through the idea of the normal consumer and in the increasing acceptance of population thinking in clinical research.Footnote 63 It is perhaps not surprising that we also find this happening in a system which operated on the medico-legal comparison of a disabled person and an idealized normal person. The key change was that this comparison was made by law into a common object of knowledge: the aetiologies of diverse disorders were discussed and debated in Parliament in the pursuit of a fair deal for disabled veterans.
Making invalidity fair meant ensuring that the government was held to the standards of legal procedure in its award of war disability pensions. Moreover, in the case of schizophrenia, it also meant using legal means to force the psychiatric profession to be more honest about the limits of its disease theories. As this paper has documented, the interaction of medical and legal epistemic practices produced a hybrid entity, what I have called stress-triggered schizophrenia, as a working solution to the problem of medical uncertainty. In the face of medical uncertainty over the causes of schizophrenia, a political solution emerged through the creation of a legally sympathetic environment for pension claimants. However, pursuing justice on uncertain epistemic grounds created results which highlighted the politically selective nature, and ultimate unfairness, of the whole system. That a senior-ranked military man could receive a lucrative disability pension for a disease which would be considered undeserving of the same state welfare when it occurred in civilian life was a political injustice which was clear to those in the WPD but remained tolerated by the post-war public.Footnote 64 While the pursuit of legal procedure led to the qualification of medical certainty about the causes of schizophrenia, it could not solve the problem of political fairness, as individuals who were less needy than others ended up receiving greater assistance. This constellation of problems remains at the centre of contemporary welfare politics and the balancing of economic exigence and popular sympathies.
Before 1950 most psychiatrists saw genetic research in eugenic terms as having economic and political implications. By the 1970s psychiatrists had learned to be more honest with the public about the limited validity of their disease theories. Following the rapid political decline of eugenic thinking, psychiatrists adopted the so-called biopsychosocial model of mental illness, which took into account the interaction of genetics and neurobiology with the various acute and chronic stresses of modern life. Subsequently there has been a tendency to emphasize environmental factors, epigenetics and the hope that genetic research will help improve treatments. However, the continuation and steady growth of research into the genetic aetiology of schizophrenia also owe to the fact that, within a biomedical framework, the genetic theory remains the best bet for validating a specific disease theory of schizophrenia. As in the war pensions system, the evidence of hereditary aetiology from twin studies remains the core of the medical profession’s claim to identify an underlying natural disease entity and to exclude stress in causal explanations. Moreover, it remains the case today that, as a recent historical survey has concluded, while people with schizophrenia do ascribe importance to genetic explanations, the ‘precipitating factors’ that result in ‘outright illness may be given more weight by those with lived experience than by mental health scientists’.Footnote 65
The sociologist of science Adam Hedgecoe argues that post-war genetic researchers, in their elaboration of diathesis-stress models for schizophrenia, nonetheless retained a commitment to a disease model rooted in a specific genetic predisposition which downplayed environmental factors.Footnote 66 However, it is important to recognize that when genetic researchers discredit environmental factors, they are arguing that these environmental factors cannot be necessary causes. All this means is that without the genetic variance, no matter how many other factors are present, you will not get schizophrenia but something else. As the clinical psychologist Paul Meehl pointed out in his presidential address to the American Psychological Association in 1962, accepting that there is a necessary genetic aetiology for schizophrenia does not entail that this factor always causes the disease, that it determines the symptom severity and the course of illness, or that the only effective therapies will target that aetiology.Footnote 67 In other words, a genetic aetiology doesn’t entail genetic reductionism. Ultimately, the public debates over these theories are less about the genetic evidence and more about the social role and function of specific disease entities. While in research contexts the genetic aetiology remains a hypothesis within a shared horizon of specified ignorance about the pathogenesis of schizophrenia, in everyday parlance the specific disease entity is the cause of the patient’s problems. The problem is not genetic research per se, but the reductionist ends to which specific disease entities are put.Footnote 68 The interaction of medical and legal systems under conditions of uncertainty may only reinforce this reductionism, not in the name of genetics, but in the service of regulation.
Acknowledgements
I want to thank Lara Keuck and Angela Creager for their intellectual stewardship of the Validation and Regulation in the Health Sciences project, as well as the participants in our many meetings who helped me develop my ideas for this paper. I would also like to thank Rhodri Hayward for his insights on earlier drafts of this paper, Victoria Hooton for helping me understand English administrative law, Andy Porter for his helpful comments on patient narratives and the anonymous reviewers for their encouraging feedback. Much of the research on which this article is based was carried out at the Max Planck Institute for the History of Science (MPIWG), Berlin.
Competing interests
The author declares none.
Appendix: schizophrenia cases in the PATs from 1944 to 1982
Cases marked with an asterisk (*) are from the ministry or PAT archives; all others are from the published legal reports
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