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Background: Recently, several investigators have reported an association between influenza epidemics and increased birth rates of 'preschizophrenic' individuals some four to six months later. Here we examine whether maternal exposure to other infectious diseases can also predispose the foetus to later schizophrenia., Method: Two independent sets of dates of birth of first admission schizophrenic patients, born between 1938 and 1965 in England and Wales, were obtained from the Mental Health Enquiry in England and Wales. Data on the number of deaths per month from 16 infectious diseases between 1937 and 1965 in England and Wales were also collected. We used a Poisson regression model to examine the relationship between deaths from infectious diseases and schizophrenic births., Results: In the two separate data sets, increased national deaths from bronchopneumonia preceded, by three and five months respectively, increased numbers of schizophrenic births. We did not find any other significant associations between schizophrenic births and any of the other 15 infectious diseases., Conclusions: The association between deaths from bronchopneumonia and increased schizophrenic births some months later may be a reflection of the fact that bronchopneumonia deaths increase markedly during influenza epidemics.

The epidemiological evidence that the offspring of women exposed to influenza in pregnancy are at increased risk of schizophrenia is conflicting. In an attempt to clarify the issue we explored the relationship between the monthly incidence of influenza (and measles) in the general population and the distribution of birth dates of three large series of schizophrenia patients--16,960 Scottish patients born in 1932-60; 22,021 English patients born in 1921-60; and 18,723 Danish patients born in 1911-65. Exposure to the 1957 epidemic of A2 influenza in midpregnancy was associated with an increased incidence of schizophrenia, at least in females, in all three data sets. We also confirmed the previous report of a statistically significant long-term relationship between patients' birth dates and outbreaks of influenza in the English series, with time lags of -2 and -3 months (the sixth and seventh months of pregnancy). Despite several other negative studies by ourselves and others we conclude that these relationships are probably both genuine and causal; and that maternal influenza during the middle third of intrauterine development, or something closely associated with it, is implicated in the aetiology of some cases of schizophrenia.

We examined the relationship between the dates of births of schizophrenic patients admitted to hospitals for the first time in England and Wales between 1970 and 1979, and the occurrence of influenza epidemics between 1939 and 1960. Our results indicate that exposure to influenza epidemics between the third and seventh month of gestation is associated with schizophrenia in adult life. The hypothesis that maternal viral infection is an important cause of schizophrenia can explain many aspects of the enigmatic epidemiology of the condition.

In two series of psychiatric patients (numbering about 6,000 and 2,000 respectively), the mean age of the mothers at the time of the patients' birth was found to be very significantly above expectation from the general population, and this was so for each of the major diagnostic groups. In the second series, the age of the fathers was also found to be very significantly above that expected from a sample survey of the general population, and this was so for each diagnostic group. Fathers' age was raised more than mothers', and was highest for schizophrenia. The raised parental age could not be explained in terms of the patient's year of birth or his father's social class. The raised mothers' age could largely be accounted for by regression on the raised fathers' age. The present findings, and those of previous studies, seem best explained on the hypothesis of a constitutional parental trait leading to delayed marriage.

Parental age (at patient's birth) and birth order were studied in 623 male and 89 female patients diagnosed as homosexual, who were born in England and Wales and first attended the Maudsley Hospital between the years 1961-1975. For male patients, mean parental ages were significantly higher than expectation, and mean birth order was significantly later. Regression analysis indicated that the raised fathers' age was probably of more aetiological importance than the raised mothers' age. The results confirm those of previous studies. The female patients did not show a raised parental age or late birth order.

The paper continues a review of clinical conditions and dilemmas which featured in Asylum practice during the years 1850-1950 in Britain. The rise and fall of 'Physiognomy' as a diagnostic aid and as an indicator of quality of asylum care is outlined. The problem of incontinence and the use of the ice cold douche as a therapeutic intervention in this and other forms of 'indolence or perversion' is reviewed from the writings of those who expressed opinions of these subjects at the time. Likewise, Destructive Behaviour, which was dealt with by means of 'strong clothes', presented a familiar problem. As in Part I of this review, the author concludes with a discussion of the causes and consequences of the changing faces of conditions seen in psychiatric hospitals. Viewed from the present, the changing nature of asylum insanity is apt to be forgotten and adverse judgment is apt to be applied to past practices.

Conditions which had an historical association with Asylums in the years 1850-1950, but which are no longer commonly seen in psychiatric practice, are reviewed. These include: Asylum pellagra, Erysipelas, Insane Ear and Fractured Ribs. The history of each condition and its manifestation is reviewed in the context of its relationship with mental illness and its treatment as seen by authorities writing when these conditions were prevalent. It is not clear why these conditions became common, why they had a particular association with Asylums, or why they have largely disappeared.

Seasonal variation in the rates of stillbirth, and of deaths under the age of one year, were studied for England and Wales in order to examine (a) changes in the seasonal variation over the years and (b) the correlation between seasonal rates and seasonal temperatures. The quarterly rates of stillbirths were studied for the period 1928-78; and of deaths under the age of one year, in six different age groups, for the period 1912-78. A disappearance of seasonal variation in rates ('deseasonality') occurrred from stillbirths in about 1950, and for neonatal deaths in about 1965. For deaths at 1-2 months a trend towards deseasonality has been apparent since 1955, but there has been no such trends for deaths at 3-11 months of age. In the period before deseasonality, and for the first quarter of the year, there was a high negative correlation between the neonatal death rate and the mean temperature in England and Wales but this correlation fell as the seasonal variation in rates fell. The findings suggest that seasonal variation in the neonatal death rate was closely related to winter temperatures during the period 1921-60. For deaths at 1-11 months old, there has been and still is a relation between temperature and seasonal variation in rates, but the relation was less close than for the neonatal death rate.

The quarterly distribution of births of patients born in England and Wales 1921-60 and first admitted in 1970-75 was examined by decade of birth and by age at year of admission. For patients with schizophrenia and affective psychosis, the distribution varied: in the early decade (1921-30), and for older patients (45-54 years) the proportion of births in the fourth quarter of the year was high, compared with expectation from live births in the general population; but it became lower in succeeding decades and for younger age groups. No comparable change occurred for births of patients with neurosis or personality disorder.

Inpatient admissions to all psychiatric hospital beds in England and Wales in 1970-73 were studied by month of admission for eight diagnostic groups. The admission rates for schizophrenia showed a pronounced seasonal variation, with a maximum in summer. The seasonal pattern for schizophrenia was very similar to the one shown for mania, although somewhat less marked. The admission rates for neurosis and for the large group of 'all other non-psychotic mental illness' showed little evidence of seasonal variation as there was could largely be explained by social factors. In schizophrenic and manic patients, the pattern of seasonal admissions (peak months July and August) is similar to the pattern reported for their births (peak months February and March). This is consistent with the hypothesis of an abnormal seasonal pattern of parental conception as the cause of the abnormal birth pattern.

The sex ratio of the full siblings was examined for 279 patients with schizophrenia, 416 with affective psychosis, and 1259 patients with other psychiatric diagnoses. An overall excess of brothers was found, but there was no significant difference in the sibling ratio between any of the diagnostic groups. The excess of brothers probably reflects the pattern of live births in the general population.

The season of birth of the siblings of psychiatric patients was studied to test the hypothesis that an unusual seasonal pattern of maternal conception is the cause of the excess of births in the early months of the year which has been found in national studies of psychotic patients. Information on the month of birth of the siblings was obtained from interviews with psychiatric in-patients born in Britain. The quarterly distribution of births of 670 mentally well siblings of psychotic patients (schizophrenia and manic-depression) was significantly different from that of 1,513 siblings of other psychiatric patients and also from that of all births in England and Wales. The results lend qualified support to the hypothesis, but they were not clear-cut and there was some evidence that the information on birth dates was biased.

National series of psychiatric inpatients studied in Scandinavian countries and in England and Wales have all shown that compared with live births in the general population, schizophrenic patients have a significant excess of births in the early months of the year. But there has been disagreement on whether a similar birth distribution holds for manic-depression. The present paper presents new data on the seasonal distribution of births of patients born in England and Wales between 1921 and 1955. Compared with all live births, manic-depression was associated with a significant excess of births in the first quarter, and a corresponding deficiency in the third quarter of the year. Neurotic depression showed no such association. Possible reasons for the disagreement among national findings for manic-depression include difference in the proportion of first ever admissions in the series, differences in age structure, and differences in diagnostic practice and classification. The importance of the age structure of a series is considered in relation to: a) the possible effect of age on the manifestation of a disorder associated with some seasonally related constitutional damage; b) the possibility of secular variation in the severity of a seasonally related noxious factor; and c) the effect of age incidence on distorting the expected seasonal distribution of births in any series of cases.